The purpose of this bulletin is to highlight evidence-based practices for the treatment of Opioid

Use Disorder (OUD) and coverage of these services by the Medicaid Addiction and Recovery Treatment Services (ARTS) program and to invite providers to a webinar on February 14, 2019.  ARTS aligns coverage with the current evidence to provide the best outcomes for Medicaid members with an OUD, emphasizes the importance of providing care that is responsive to individual patient preferences, needs and values, and supports Medicaid providers to effectively address the needs of members with OUD.  DMAS’ goals are to minimize treatment barriers for members who have an OUD while ensuring these members obtain access to high quality Medication Assisted Treatment (MAT) and other proven therapies.

 ARTS Alignment with Evidence-Based Practices

Below is a summary of the current evidenceⁱ and coverage through the ARTS benefit. Nothing in this summary is intended to eliminate the need to follow the Virginia Board of Medicine (BOM) regulations concerning the prescribing of buprenorphine for addiction treatment.

• DMAS supports same day access and initiation of pharmacotherapy for individuals with OUD presenting to any American Society of Addiction Medicine (ASAM) level of care.
• Maintenance pharmacotherapy should be prescribed based on the individual’s treatment needs, without arbitrary tapering or time limits. 
• No prior authorization is required for the preferred buprenorphine/naloxone product, Suboxone films, prescribed by in-network buprenorphine waivered practitioners who are credentialed and contracted with the Medicaid Managed Care Organizations (MCOs) for managed care enrolled members or DMAS enrolled buprenorphine-waivered practitioners for fee-for-service members. Evidence exists that some individuals may benefit from buprenorphine doses greater than 16 milligrams

per day through higher rates of treatment retention and abstinence from illicit substancesⁱⁱ.  Therefore, DMAS does not require prior authorization for doses up to 24 milligrams per day of Suboxone films for in-network practitioners.  

• Providers shall continue to follow the BOM guidelines regarding dosing during the induction phase as well as maximum prescribing dosages.  Please note that the BOM requires documentation in the member’s record to support prescribed doses of greater than 16 milligrams per dayⁱⁱⁱ.
• Non-preferred buprenorphine products such as the buprenorphine monoproduct and buprenorphine/naloxone tablets continue to require a prior authorization by DMAS/Magellan Pharmacy Benefit Manager (PBM) and the Medicaid MCOs.

• Diversion and misuse of buprenorphine/naloxone may still occur but is relatively rare in comparison to diversion and misuse of prescription opioid pain medications. The most commonly cited reason is to manage the negative side effects of opioid withdrawal. 
• Members who receive a prescription for buprenorphine products are no longer automatically “locked-in” to a prescriber or group of prescribers.  However, if there are identified patient safety concerns, a “lock-in” may still be instituted.  Prescribers are still required to be credentialed and contracted with the Medicaid MCO for their members and enrolled with DMAS for fee-for-service members, for the prescriptions for opioid treatment to be covered by Medicaid.  Prescription coverage will continue to be denied when prescribed by out-of-network practitioners.
• DMAS requires the co-prescribing of the overdose reversal agent naloxone with buprenorphine containing products since individuals with OUD are at elevated risk for overdose. When possible, family members and significant others should also be trained in the use of naloxone. DMAS/Magellan PBM and the Medicaid MCOs cover naloxone at no cost to the member.
• DMAS supports the integration of medical services with addiction services including clinically indicated infectious disease testing such as HIV, Hepatitis A/B/C, syphilis, and tuberculosis testing for members with OUD at initiation of and as indicated during treatment.  DMAS also covers Hepatitis C treatment and HIV treatment and prevention including pre-exposure prophylaxis.  Hepatitis C treatment is covered for all Medicaid members with any fibrosis score.  Primary care providers can prescribe preferred drugs such as Mavyret (glecaprevir/pibrentasvir) without a referral to a specialist.  Members should not be denied treatment for Hepatitis C for the sole reason of Substance Use Disorder.  Please see the DMAS Preferred Drug List for more information: https://www.virginiamedicaidpharmacyservices.com/provider/preferred-dru…
• DMAS supports integration of reproductive health services including contraception with addiction treatment.  DMAS and the Medicaid MCOs cover all family planning medications and devices including long acting reversible contraception (LARC) without a prior authorization.
• DMAS follows the BOM regulations, which requires members to be assessed and referred for substance use disorder counseling and/or psychotherapy. However, current evidence on the value of requiring counseling and/or psychotherapy with opioid use disorder is mixed, and some members may benefit more than others^iv. During the course of their treatment, some members may be unable or unwilling to engage in counseling and/or psychotherapy. For these individuals, it is essential that they remain on pharmacotherapy, since pharmacotherapy alone can reduce the risk of mortality from OUD by as much as 60 percent. Therefore, DMAS does not require members to accept ongoing counseling and/or psychotherapy as a condition of receiving pharmacotherapy.  If counseling and/or psychotherapy is discontinued, the reasons should be documented in the member’s medical record. 
• DMAS allows and encourages same-day billing of medical and behavioral health services (i.e., if an obstetrician is providing prenatal care and addiction care in the same visit, these are both covered) to support integrated medical services and addiction services.  Providers should contact the Medicaid MCOs to determine the appropriate modifier to place on claims (such as “GB” or “25”) which defines the services as separate and distinct from each other to support billing.  The MCO provider contact numbers are located on the back of the member’s MCO ID card. For members enrolled in fee-for-service, Magellan of Virginia will continue to cover MAT.  The medical visit not related to the OUD would be billed to DMAS directly.  Please visit the ARTS Reimbursement Chart for specific details of what Magellan of Virginia covers for fee-for-service members:  http://www.dmas.virginia.gov/#/arts.
• DMAS supports home induction on buprenorphine products in accordance with the ASAM National Practice Guideline. 
• Relapse to opioid use is a common occurrence among individuals with OUD. DMAS encourages providers to use urine drug testing as a therapeutic tool and not to discharge patients based on relapse and/or positive drug test results. Upon discovering relapse, providers should re-assess a patient’s condition, their adherence, their dose of pharmacotherapy and behavioral treatment, and consider intensification of care. 
• DMAS requires Medicaid providers for ARTS Intensive Outpatient Programs (IOPs), Partial Hospitalization Programs (PHPs) and Residential Treatment Services (RTS) to ensure that Medicaid and FAMIS enrolled members with OUD admitted to any of these programs be evaluated for and have access to evidence-based MAT, including buprenorphine. 
• The introduction of pharmacotherapy for OUD prior to and immediately after release from institutional settings, such as hospitals, inpatient rehabilitation facilities, and jails, can reduce the elevated risk of fatal overdose related to loss of tolerance^v. 
• DMAS is updating the Preferred Office-Based Opioid Treatment (OBOT) Credentialing checklist to align with these evidence-based practices, as well as the Preferred OBOT Model of Care and Attestation form. This form will be required for new Preferred-OBOT applicants effective March 1, 2019.  Instructions for applying for Preferred OBOT status may be found online at: http://www.dmas.virginia.gov/#/artscredentialing under “Office Based Opioid Treatment.”  

February 14, 2019 Webinar: Evidence-Based Practices for Treatment of Opioid Use Disorder and ARTS Coverage

DMAS is facilitating a webinar on February 14, 2019 from 12:00 p.m. – 1:30 p.m., for all ARTS Preferred OBOT Providers and other MAT providers to review these evidence-based practices and ARTS coverage. The expert presenter is Dr. Mishka Terplan, MD, MPH, FACOG, DFASAM, Professor in Obstetrics and Gynecology and Psychiatry, Associate Director in Addiction Medicine at Virginia Commonwealth University, and Addiction Medicine Consultant with DMAS. 

Click Here to Register

After your request has been approved, you will receive instructions for joining the meeting. If you already registered for this meeting, you do not need to register again.

For additional questions about this bulletin or the ARTS benefit, please email:  SUD@dmas.virginia.gov or call (804) 593-2453.

Medicaid Expansion

New adult coverage begins January 1, 2019.  Providers will use the same web portal and enrollment verification processes in place today to verify Medicaid expansion coverage.  In ARS, individuals eligible in the Medicaid expansion covered group will be shown as “MEDICAID EXP.”  If the individual is enrolled in managed care, the “MEDICAID EXP” segment will be shown as well as the managed care segment, “MED4” (Medallion 4.0), or “CCCP” (CCC Plus).  Additional Medicaid expansion resources for providers can be found on the DMAS Medicaid Expansion webpage at:  http://www.dmas.virginia.gov/#/medex.