TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers, and Nursing Homes
Effective April 1, 2020, the Alabama Medicaid Agency will implement hard edits on cumulative daily MME claims exceeding 150 MME/day. A phase-in period for claims exceeding 120 MME/day, but less than 150 MME/day, will also be implemented.
Higher doses of opioids are associated with higher risk of overdose and death - even relatively low dosages (20-50 MME per day) may increase risk.1 Therefore, Alabama Medicaid will limit the amount of cumulative MME allowed per day on opioid claims. The edit began at 250 cumulative MME per day and is gradually being decreased over time. The final cumulative MME target is scheduled to be 90 MME per day.
Hard Edit Implementation (Greater than 150 MME):
Effective April 1, 2020, opioid claims that exceed a cumulative MME of 150 MME/day will be denied. The universal PA 0009996323 will no longer be valid to bypass the 150 MME edit. Pharmacy override requests for quantities exceeding the MME limit may be submitted to Health Information Designs (HID) and will be reviewed for medical necessity. See the link below for an override form.
Phase-In Period (120 MME - 150 MME):
Effective April 1, 2020, claims that exceed the cumulative daily MME limit of 120 MME/day will be denied. The dispensing pharmacist will be provided a universal prior authorization (PA) number on the rejection screen and may enter this universal PA number on the claim to allow it to be paid. Pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient's total daily MME.
The universal PA number to override the 120 MME (but less than 150 MME) edit will be 0009996324.
The universal PA number will be provided on each cumulative MME rejection screen for the pharmacist's convenience.
Additional edits, such as therapeutic duplication, maximum quantity limitations, early refill, non-preferred edits, etc., will still apply.
Claims prescribed by oncologists will bypass the edit.
Long term care and hospice recipients are excluded.
Children are included in the edit.
A Recipient Information Sheet for prescribers and pharmacists to provide to recipients can be found athttp://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.1https://www.cdc.gov/drugoverdose/prescribing/guideline.html
Anticipated Phase Down:
The Agency plans to gradually decrease the daily cumulative MME limit every 4 months. The next decrease will be a hard edit on claims exceeding 120 MME/day with a phase-in edit for claims that exceed 90 MME/day. This will be implemented on August 1, 2020. Prior to each decrease, a new universal PA number will be assigned to override claims that exceed the new threshold. Providers will be notified via an ALERT prior to each decrease. Again, pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient's total daily MME
Examples of MME calculations/day include:
10 tablets per day of hydrocodone/acetaminophen 5/325 = 50 MME/day
6 tablets per day of hydrocodone/acetaminophen 7.5/325 = 45 MME/day
5 tablets per day of hydrocodone/acetaminophen 10/325 = 50 MME/day
2 tablets per day of oxycodone 15 mg = 45 MME/day
3 tablets per day of oxycodone 10 mg = 45 MME/day
10 tablets per day of tramadol 50 mg = 50 MME/day
1 patch per 3 days of fentanyl 25mcg/hr = 60 MME/day
Once the hard edit is implemented, the MME Cumulative Daily Override Form will be used by the prescriber when requesting an override. The form will be found at:
Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at
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