Prescription Drug Program: New Methadone Dose Limit

HCA Apple Health

Dear Provider:

Effective for dates of service on and after March 1, 2016, Washington Apple Health (Medicaid), administered by the Health Care Authority (the agency), will implement the new dose limit of 40mg per day for methadone.

The agency is implementing a daily dose limit for methadone as directed by the Washington Medicaid Drug Utilization Review board due to concern over the high number of methadone-related fatalities in the State of Washington.

The agency will allow clients currently receiving methadone above the 40mg per day limit to continue receiving methadone without authorization when the agency has record of payment for methadone for these clients in the last two months. Dose increases beyond the client’s 40mg per day dose will require prior authorization.

The agency will also continue to cover methadone without restriction for clients actively being treated for cancer pain, using expedited authorization (EA) code 85000000040.

For clients new to Washington Apple Health for whom the agency does not have current record of payment for methadone, but who have been actively taking methadone paid for out-of-pocket or by another payer, pharmacies may request authorization by calling 1-800-562-3022 ext. 15483, and indicating that the methadone is a continuation of current treatment for the client.

For more information, see the agency’s Washington Preferred Drug List (WPDL) and Expedited Authorization List (EA).

For more information, see the agency’s Washington Preferred Drug List (WPDL) and Expedited Authorization List (EA).