Pharmacy Pain Management Protocol Pharmacy Policy and Protocol

Transcription

1 Line of Business: Medicare and Medi-Cal Effective Date: November 18, 2015 Renewal Date: August 16, 2017 Pharmacy Pain Management Protocol Pharmacy Policy and Protocol This protocol has been developed through review of medical literature, consideration of medical necessity, generally accepted medical practice standards, and approved by the IEHP Pharmacy and Therapeutic Subcommittee. Goals: Proactively manage members on multiple narcotic medications to prevent overutilization, identify unsafe and inappropriate opioid use, and address potential fraud/waste/abuse. Comply with the Centers for Medicare and Medicaid Services (CMS) drug utilization management (DUM) requirements of 42 C.F.R et seq. to prevent overutilization of opioids. Background: The Centers for Medicare and Medicaid Services (CMS), with the administration of the controlled substance overutilization monitoring system (OMS) for the Medicare Part D program, requires plan sponsors to implement a reasonable and appropriate drug utilization review (DUR) program to assist in the prevention of controlled substances overutilization. By adapting and endorsing CMS supplemental guidance, this policy describes IEHP s implementation of DUR components, methodology of clinical case management, documentation, data sharing between plans and written notification to prescribers and members as part of clinical case management. Policy and Procedures: I. Methodology to Identify Potential Opioid Overutilizers 1. The Sponsor Plan Identified (SPI) opioid overutilization report, a retrospective drug utilization review, is utilized to enhance patient safety by monitoring opioid overutilization, and to reduce fraud, waste and abuse. a. Opioid outliers are identified by following criteria: i. Daily Morphine Equivalent Dose (MED) > 120 for at least 90 consecutive days ii. More than 3 prescribers iii. More than 3 pharmacies

2 iv. Exclude cancer diagnosis or those receiving hospice care v. Report is differentiated by line of business (Medi-Cal, Medicare) 2. ER Overutilization Report a. Identify members having minimum of 3 emergency room (ER) visits for pain diagnoses in the past 3. b. Report is differentiated by line of business (Medi-Cal, Medicare) 3. CMS identified potential overutilizers a. Quarterly report of patients identified by CMS for potential opioid overutilization b. TRR notices for the active POS edit indicator in MARx II. Medicare Pain Management Program 1. Enroll members identified by the SPI report, CMS quarterly report and/or MARx TRR notices. 2. Enroll outlier members with excessive ER utilization 3. Enroll members with suspicious drug seeking behavior identified by Compliance and/or pharmacy operation. 4. Initial Review a. Clinical Pharmacy Program Specialists (PPS) and/or Pharmacy Coordinator (PC) conduct Argus claim research by completing Argus research template (see appendix) b. Clinical Pharmacists provide CURES reports c. PPS/PC complete pain evaluation template and provide preliminary recommendation: i. Presence of suspicious drug seeking behavior (DSB), overutilization issues, and/or inadequately managed pain ii. Assess the need to discuss with prescriber the option of restricted authorization, RA (beneficiary-level POS opioid claim edit) iii. Assess the need to make referrals to Compliance (fraudulent activity), and/or Case Management nursing team (specialist referral) 5. Pharmacist Secondary Review a. Review PPS/PC recommendation and summary of research b. Decision to contact Prescribers for overutilization issues, option of RA, referrals to Compliance, and/or Case Management nursing team 6. Communication with Provider a. At least 3 attempts to speak to prescriber and/or written inquiries to prescriber with CMS pre-approved letter template b. Present findings to Provider c. For overutilization issues with DSB: discuss with Provider the option of RA and specialist referral d. For possible inadequate pain management issues: discuss with provider option of pain management referral, and/or schedule a followup appointment with member 7. Documentation a. Argus research/paid claims summary

3 b. CURES report c. Pain evaluation summary d. Documentation of communications with prescribers, number of attempts, results of communication, date of written inquiries sent to Prescribers, Compliance notification, date of RA implementation, date of member letter sent, and date of CM task e. Copy of written inquiries to Prescribers f. Copy of letter sent to member when RA is indicated 8. When RA is implemented as a result of communication with Provider a. Mail CMS pre-approved letter to member at least 30 days in advance of RA implementation b. Submit RA (beneficiary-level POS opioid claim edit) to CMS via MARx c. Forward a copy of member letter to provider who have nonetheless asked for information on their patient s opioid use for treatment purposes d. RA will be re-evaluated after 12, unless requested to be done earlier by member or provider 9. CMS reporting a. PPS submit RA (beneficiary-level POS opioid claim edit) to CMS via MARx b. Pharmacists to submit OMS quarterly response forms to CMS i. PS1 and PS2 response codes are applied based on implementation date submitted in MARx for the POS edit c. PPS ed a copy of member letter to CMS mailbox 10. Compliance a. PPS/PC report to Compliance when fraudulent activities are involved 11. Case Management Nursing Team Referral a. PPS/PC task to CM nursing team when Prescribers agree that member will benefit from specialist referral 12. Data sharing among sponsors a. PPS transfer records/documentation upon new sponsors requests b. PPS to run TRC322 query report that identifies active POS edit indicator in MARx/Voyager i. PPS request records from former sponsors upon receiving notice that members with history of beneficiary-level POS opioid claim edit are newly enrolled to IEHP ii. Enroll members to Medicare Pain Management program (II) for full review III. Medi-Cal Pain Management Program 1. Enroll members identified by SPI report and ER overutilization report 2. Enroll members with suspicious drug seeking behavior reported by Compliance and/or pharmacy operation. 3. Follow the same procedures as Medicare Pain Management Program II.3- II.5, II.10 II.11

4 4. When members are identified with a history of cash payments for narcotics, mail letter to members entailing that all medically necessary medications are covered by IEHP and must be obtained through the established guidelines (i.e. prescription prior authorization). 5. When non-contracted IEHP providers are identified with prescribing narcotics, task case to Care Management team to educate member the importance of seeing IEHP contracted provider. Mail the Non-Par letter to member. 6. Documentation a. Argus research/paid claims summary b. Pain evaluation summary c. Documentation of communications with prescribers, results of communication, Compliance notification, date of RA implementation, date of CM task Appendix: Letter Template 1) CMS pre-approved letter templates per September 2012 CMS supplemental guidance 2) PDF copies of each letter located in each member s folder Pain Evaluation Template for (member name) Pain Evaluation Items Number Concern (Y/N) Daily Morphine Equivalent Dose Y if > 120 MED (MED) based on recent monthly use # of unique opioid drugs in the last 3 # of prescribers in the last 3 # of pharmacies in the last 3 Y if 5 or greater # of other unique C3-C5 drugs in last 3 # of ER/UC visits in the last 3 Other Argus Research Template Date Drug Strength Quantity Day Supply MED Claim Status Pharmacy Prescriber Specialty

5 Change Control Date Change 08/16/2017 Renewed with no updates/changes