OptumRx Initiates Opioid Risk Management
to Ensure Member Safety
  

The opioid epidemic in America has been declared a public health emergency. To help combat devastating opioid-related overdoses, hospitalizations and deaths, OptumRx has introduced their Opioid Risk Management program. This comprehensive solution is based on guidelines from the Centers for Disease Control (CDC) and offers MedCost clients and their members a multi-dimensional approach that prevents opioid misuse before it occurs, identifies and intervenes with at-risk and high-risk members, and supports those with dependency through successful recovery.

Members impacted by the Opioid Risk Management program recently received a letter from OptumRx, but they may still have questions about what the new protocols mean for them. The program will affect new-to-therapy members as well.


Quantity Limit Changes on Short-Acting Opioids

Effective July 1, 2017, OptumRx introduced quantity limits on short-acting opioids (i.e., Demerol, Percocet, Vicodin, and oxycodone).

Members who are new to opioid therapy (no opioid in their most recent 120 day claim history) will be limited to:

  • A maximum dosage of 49 morphine-equivalent milligrams per day of the medication per fill
  • A maximum of 7 days supply
  • Limit of 2 fills within a 60-day timeframe

Members who are NOT new to opioid therapy (have opioid fills in their most recent 120 day claim history) will be limited to:

  • A maximum dosage of 90 morphine-equivalent milligrams per day of the medication per fill
  • Limit of 2 fills within a 60-day timeframe
Prior Authorizations Required on All Long-Acting Opioids

Effective January 1, 2018, OptumRx requires Prior Authorization for all long-acting opioids (i.e. OxyContin, Opana, Fentanyl) to ensure clinically-appropriate, safe use of these medications on an ongoing basis. Long-acting opioids should be reserved for members who require chronic (therapy duration of 3+ months) and around-the-clock pain management, and never as initial therapy for members new to treatment.

This initiative includes:

  • Maximum daily dose quantity limits to align with the CDC’s opioid prescribing guidelines.
  • Ongoing clinical edits at point of claim adjudication to monitor opioid utilization and ensure safe use by members.

Note: For members who have an oncology drug on their profile, filled within the last 360 days, neither the quantity limit edit nor prior authorization will apply.
 
If you have any questions regarding the OptumRx Opioid Risk Management program, please contact your MedCost Benefit Services Account Manager.

1 Kolodny A, Courtwright DT, Hwang CS, Kreiner P, Eadie JL, Clark TW, Alexander GC. The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 2015; 36:559-574.
2 Centers for Disease Control and Prevention; Understanding the Epidemic: Drug Overdose Deaths in the United States Continue to Increase in 2015. Accessed Dec. 13, 2017.

Zafeira Sarrimanolis, PharmD is the Pharmacist for MedCost. She assists with pharmacy benefit planning and development and offers proactive analysis and clinical recommendations to help manage pharmacy trend.