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CMS Updates Rates and Expands Opioid Policies Under Medicare Advantage and Part D

Apr 03, 2018

On Monday April 2, CMS published the Rate Announcement and Call Letter for the Medicare Advantage and Part D programs. The 2019 Rate Change notice updates methodologies used to pay Medicare Advantage and Part D sponsors. The expected average change in revenue for 2019 is +3.40%, with the increase primarily attributable to the per capita cost growth rate. The Final Call Letter highlights CMS concerns about the opioid epidemic and outlines new policies for 2019 targeted to the distinct populations of Medicare Part D opioid users. 

  1. For opioid naïve patients, Part D sponsors are asked to implement a hard safety edit to limit initial prescriptions for the treatment of acute pain to no more than a 7-day supply. 
  2. For high risk opioid users CMS is expanding the Overutilization Monitoring System (OMS) which identifies beneficiaries considered to be at significant risk.  
  3. For chronic opioid users, Part D sponsors are expected to implement real-time safety alerts at the time of dispensing.  
  4. For opioid users also taking duplicate or key potentiator drugs, Part D sponsors are expected to implement additional soft safety edits to alert the pharmacist about duplicative opioid therapy and concurrent use of opioids and benzodiazepines. 
  5. Finally, for all opioid users, CMS is implementing technical revisions to the Pharmacy Quality Alliance opioid overuse measures and adding a new measure for concurrent use of opioids and benzodiazepines.