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The purpose of this memorandum is to inform providers about policy changes implemented by the Medicaid Fee-for-Service program and the Medicaid health plans to align with the CDC Guideline for Prescribing Opioids for Chronic Pain.  These changes will be implemented by the Medallion 3.0 health plans including Anthem HealthKeepers Plus, Aetna Better Health of Virginia (previously CoventryCares), Virginia Premier, Optima Family Care, Kaiser Permanente, and INTotal Health.

On November 21, 2016, Virginia State Health Commissioner Dr. Marissa Levine, declared that the opioid addiction crisis is a public health emergency in Virginia. In 2015, over 1,000 Virginians died due to fatal drug overdoses.  More Virginians died from drug overdoses than car accidents or homicides. Nearly 80% of these deaths involved prescription opioids or heroin.  The total number of fatal drug overdoses in Virginia during the first half of 2016 has increased 35% when compared to the same time period in 2015.  The use of evidence-based guidelines when prescribing opioids for pain management is essential to addressing this opioid addiction crisis.   

In March 2016 the U.S. Centers for Disease Control and Prevention (CDC) published the Guideline for Prescribing Opioids for Chronic Pain.  This guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up and discontinuation; 3) assessing risk and addressing harms of opioids use.   The Guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.

The Virginia Department of Medical Assistance Services (DMAS) worked with the Virginia Department of Health, Department of Health Professions, Medical Society of Virginia, and Medicaid health plans to implement uniform policies that align with the CDC Guideline across all Medicaid health plans.  These policies include:

• Coverage of naloxone injection and nasal spray (Narcan®) without prior authorization or quantity limits.
• Addition of non-opioid pain relievers without prior authorization requirements to formularies including:
  • Lidocaine patches
  • Capsaicin topical gel
  • Gabapentin
  • Duloxetine (Cymbalta®)
  • NSAIDs (oral and topical including diclofenac gel)
  • Baclofen and
  • Tricyclic antidepressants
• Pregabalin (Lyrica®) will be added to formularies with a step edit requirement (trial of gabapentin or duloxetine).
• Addition of topical and/or sublingual buprenorphine for analgesia (Butrans® or Belbuca®) to formularies as alternatives to Schedule II long acting opioids because of the lower risk of respiratory depression and fatal overdose. Will require submission of long-acting opioid PA.
• Uniform, streamlined prior authorization (PA) forms for ALL long-acting opioids and short-acting opioids prescribed in quantities greater than 14 days or greater than 120 cumulative morphine milligram equivalents (MME) per day.
• Edits or denials for concomitant use of benzodiazepines & opioids.  This is based on the black box warning from the U.S. Food and Drug Administration (FDA) for the concomitant use of opiates and benzodiazepines due to the serious risks of extreme lethargy, respiratory depression, coma and death associated with using these medications together.
• Checks of the Virginia Prescription Monitoring Program (PMP) for opioid prescriptions lasting more than 14 days with dates of the last opioid and last benzodiazepine prescribed. 
• Physician/patient agreement with goals addressing the benefits and harm of opioids.
• Urine drug screens for patients taking short-acting opioids for greater than 60 days or long-acting opioids.

These actions are critically important to the Commonwealth’s response to the opioid epidemic and were already implemented in the Medicaid Fee-for-Service program on July 1, 2016.  In the two months following the implementation of quantity limits and new prior authorization requirements in the Medicaid Fee-for-Service program, DMAS has seen a 58% decrease in the total day supply of opioids and a 53% decrease in the total drug quantity dispensed.  The number of patients receiving opioids has only decreased by 12%. 

The Medicaid health plans will implement these policies including the use of a uniform, streamlined prior authorization form for short and long-acting opioids for members receiving new prescriptions for opioids starting on December 1, 2016 and for all members on April 1, 2017.  Please see the attached Implementation Plan for CDC Guideline for Prescribing Opioids for Chronic Pain for a detailed timeline.    

COMMONWEALTH COORDINATED CARE

Commonwealth Coordinated Care (CCC) is a new initiative to coordinate care for individuals who are currently served by both Medicare and Medicaid and meet certain eligibility requirements.  Please visit the website at http://www.dmas.virginia.gov/Content_pgs/altc-home.aspx to learn more.

MANAGED CARE ORGANIZATIONS

Many Medicaid recipients are enrolled with one of the Department’s contracted Managed Care Organizations (MCO).  In order to be reimbursed for services provided to an MCO enrolled individual, providers must follow their respective contract with the MCO.  The MCO may utilize different prior authorization, billing, and reimbursement guidelines than those described for Medicaid fee-for-service individuals.  For more information, please contact the MCO directly.  Additional information about the Medicaid MCO program can be found at http://www.dmas.virginia.gov/Content_pgs/mc-home.aspx.

VIRGINIA MEDICAID WEB PORTAL

DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, payment status, service limits, service authorizations, and electronic copies of remittance advices. Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to: www.virginiamedicaid.dmas.virginia.gov.  If you have any questions regarding the Virginia Medicaid Web Portal, please contact the Xerox State Healthcare Web Portal Support Helpdesk, toll free, at 1-866-352-0496 from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays. The MediCall audio response system provides similar information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider. Providers may also access service authorization information including status via KEPRO’s Provider Portal at http://dmas.kepro.com.

“HELPLINE”                                                                                                                                           

The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except on holidays.  The “HELPLINE” numbers are:

• 1-804-786-6273           Richmond area and out-of-state long distance
• 1-800-552-8627           All other areas (in-state, toll-free long distance)

Please remember that the “HELPLINE” is for provider use only.  Please have your Medicaid Provider Identification Number available when you call.