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1 Welcome - we will begin the webinar shortly Please read the participation tips below: All guest phones have been muted: Background noises, conversations, white noise etc., can be disruptive to a webinar. Questions: All Health Partners Webinars provide 2- way conversation. Please use the Chat feature when asking questions and communicating with the host. Any questions we are unable to address today, will be answered at a later time.

2 Opioid Prior Authorization Process Provider Webinar November 9, 2017

3 Agenda Objective CDC recommendations for prescribing opioids Implementation timeline HPP prior authorization criteria Opiate Use Disorder Centers of Excellence Resources Q&A

4 Presenters Christopher Casella, PharmD, MBA Director of Pharmacy Services, Health Partners Plans Danielle Dolores, RPh Manager, Pharmacy Services, Health Partners Plans Dr. Tania Kolev, MD Medical Director, Health Partners Plans

5 Objective To obtain a full understanding of the HPP prior authorization criteria for opioid medications to allow for minimal disruption to members HPP s objective is for the member to be on the minimal dose for the shortest duration of opioid prescriptions

6 CDC guidelines This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death Assessing Benefits and Harms of Opioid Therapy:

7 Implementation Effective 9/15/17 Prior authorization requirements, members under 21 years of age* Prior authorization required for all opioid containing medications (formulary and non-formulary) prescribed when the prescription exceeds a seven (7) day supply AND will be limited to one opioid containing prescription per 365 days PA required regardless of whether the member has taken an opioid previously. This applies to all new starts and current members. Prior authorization requirements, members 21 years of age and older* Prior authorization required for opioid containing medications for NEW STARTS ONLY when the prescription exceeds a 14 day supply AND will be limited to one opioid containing prescription per 365 days *Sickle Cell and Cancer Diagnosis will NOT require a Prior Authorization

8 Implementation dosage-based Prior authorizations will be required for all opioid prescriptions that exceed a specific dose of milligrams of morphine equivalent (MME). This requirement will be applied as shown below: Date Requirement 10/16/ mg MME per day 11/13/ mg MME per day 1/1/ mg MME per day

9 Implementation 1/1/18 Prior authorization will be required for all opioid containing medications regardless of prior therapy when the following parameters are met*: Prescription exceeding a seven (7) day supply for members less than 21 years of age Prescription exceeding a 14 day supply for members 21 years and older More than one (1) opioid containing prescription in 365 days Prescription exceeding a daily dosage of 90 MME *Sickle Cell and Cancer Diagnosis will NOT require a Prior Authorization

10 Prior authorization requirements Non-pharmacological treatment failure Non-opiate analgesics failure Diagnosis w/ chart notes Treatment plan PDMP check Urine drug screen Taper schedule Risk factors addressed Concurrent BDZ use Naloxone offered Pain assessment documentation More information Visit hpplans.com/providers

11 Approval duration Initial review may be approved up to three (3) months duration OR the duration of the taper plan submitted, both at Medical Director s discretion. Continuation of therapy will be approved if all criteria met for up to three (3) month duration OR taper plan duration if provided.

12 Continuation of Therapy Letter If further therapy is required, Health Partners will need the following information to review your case:1) Copy of chart notes documenting the diagnosis including documentation of symptoms, imaging, or other testing which supports the diagnosis; 2) Medication history; 3) Documentation of failure, intolerance, or contraindication to non-pharmacologic treatment and non-opioid analgesics; 4) Documentation of severe pain documented by a pain assessment tool; 5) If diagnosis is neuropathic pain or migraine headaches, documentation showing first line medications for neuropathic pain or migraine headaches have been tried; 6) Documentation of the duration of treatment, treatment plan, and taper plan; 7) Documentation showing the patient has been counseled regarding adverse effects, and the risk of addiction, abuse, and misuse; 8) Evaluation for potential misuse and abuse completed including family and social history; 9) Confirmation that the provider has checked the PDMP (Pennsylvania Prescription Drug Monitoring Program); 10) Confirmation that urine drug screen is consistent with prescribed medications; 11) If concurrent use of benzodiazepine and opioid, documentation of a taper plan to decrease the dose of either benzodiazepine or opioid (taper plan can be for tapering one medication at a time); 12) Evaluation of factors which increase the risk for opioid related harm and if a prescription for naloxone has been provided; 13) For long acting narcotic analgesics, documentation showing failure of short-acting narcotic analgesic.

13 Non-Pharmacologic Treatment Acupuncture Aqua therapy Physical therapy Chiropractic Nerve blocks

14 Tapering Plan Taper plan should be Individualized It depends on Dose Drug Duration of treatment Conservative taper schedule is 5% to 10% decrease in the total daily dose q 4 weeks For medical contraindication or side effects - consider more rapid/ aggressive taper

15 Monitoring Regularly Check the PDMP Test Random periodic UDS (Eligible for reimbursement) G0480 Drug test(s), definitive - 7 drug classes; G drug classes, G drug classes, G or more drug classes If UDS is negative for the drug and you suspect diversion - discontinue it immediately. We will not allow a renewal

16 Concurrent Benzodiazepine Use Prior Authorization will require a taper plan of either BDZ, Narcotic, or both if patient is on concurrent therapy due to potential safety issues: Side Effects Both cause sedation and respiratory depression (the cause of overdose fatality) Both can cause addiction (Black box warning against combined use) Risk of Death: In 2015, 23% of people who died of an opioid overdose also tested positive for benzodiazepines.

17 Opioid Conversion Opioid Rotation Consider reducing the starting dose by 30-35% due to lack of cross tolerance. Dosing Know the total morphine milligram equivalent (MME) Use charts or conversion calculators

18 Opioid Conversion Calculators Study showed accuracy of opioid conversion improved from 68% to 81% by using a calculator

19 MME Conversions Drug Oxycodone 60mg/day Oxycodone 80mg/day Oxycodone 160mg/day Hydromorphone 23 mg/day Hydromorphone 30 mg/day Hydromorphone 60 mg/day Hydrocodone 30mg Fentanyl 25mcg/hour Fentanyl 50mcg/hour Fentanyl 100mcg/hour Methadone 30mg 90 MME 120 MME 240 MME 90 MME 120 MME 240 MME 30 MME (1:1 Ratio) 60 MME 120 MME 240 MME 90 MME MME

20 Examples of 240 MME Drug Percocet 5/325mg Oxycodone 10mg OxyContin 40mg Norco 5/325mg Norco 7.5/325mg Morphine IR 15mg Morphine ER 20mg Morphine ER 60mg Methadone 10mg Hydromorphone 8mg Fentanyl 100mcg/hour Max perday; Max per month 32 per day; 960 per month 16 per day; 480 per month 4 per day; 120 per month 48 per day; 1440 per month 32 per day; 960 per month 16 per day; 480 per month 12 per day; 360 per month 4 per day; 120 per month 8 per day; 240 per month 7 per day; 210 per month 1 patch every 72 hours; 10 patches a month

21 Examples of 120 MME Drug Percocet 5/325mg Oxycodone 10mg OxyContin 40mg Norco 5/325mg Norco 7.5/325mg Morphine IR 15mg Morphine ER 20mg Morphine ER 60mg Methadone 10mg Hydromorphone 8mg Fentanyl 50mcg/hour Max perday; Max per month 16 per day; 480 per month 8 per day; 240 per month 2 per day; 60 per month 24 per day; 720 per month 15 per day; 450 per month 8 per day; 240 per month 6 per day; 180 per month 2 per day; 60 per month 4 per day; 120 per month 3 per day; 90 per month 1 patch every 72 hours; 10 patches a month

22 Examples of 90 MME Drug Percocet 5/325mg Oxycodone 10mg OxyContin 40mg Norco 5/325mg Norco 7.5/325mg Morphine IR 30mg Morphine ER 20mg Morphine ER 60mg Methadone 10mg Hydromorphone 8mg Fentanyl 25mcg/hour Max perday; Max per month 12 per day; 360 per month 6 per day; 180 per month 1 per day; 30 per month 18 per day; 540 per month 12 per day; 360 per month 3 per day; 90 per month 4 per day; 120 per month 1 per day; 30 per month 3 per day; 90 per month 2 per day; 60 per month 1 patch every 72 hours; 10 patches a month

23 Temporary Supply Members are eligible for a temporary supply of medication that deny for prior authorization once per year per medication Pharmacist receive a code that can be entered at pharmacy for a 5 or 15 day temporary supply 5 days for new starts 15 days for ongoing treatment If medication filled within the last 34 days This will NOT override prescriptions denying due to high MME

24 Opioid Rx > 14 day supply YTD

25 Opioid Rx > 14 day supply YTD

26 Opioid Use Disorder Center of Excellence (OUD COE) Prior Authorization is NOT required for treatment of opioid use disorder if the Prescriber s NPI is associated with a Center of Excellence(COE) The following medications will apply: Suboxone(16mg of less) Buprenorphine Tablets(16mg or less) Vivitrol DUR restrictions will still apply

27 Southeast OUD COEs Philadelphia County Temple TWO Program/The Wedge Pathways/Project Home/Prevention Point (The Steven Klein Wellness Center) Penn Presbyterian Medical Center/Penn Medicine Mothers Matter Program Public Health Management Corporation (PHMC) Jefferson Maternal Addiction Treatment, Education, and Research (MATER)/Narcotic Addiction Rehabilitation Program of Thomas Jefferson University* * Not directly contracted w/hpp Bucks Penn Foundation, Inc.* (Sellersville) Family Service Association of Bucks County* (Langhorne) Delaware Center for Integrative Medicine (AIDS Care Group) (Chester) Crozer-Chester Medical Center* (Chester) Montgomery Community Health & Dental Care, Inc. (Pottstown) Resources for Human Development, Inc. (Norristown)

28 COE Resources PA Department of Health- Opioid Prescribing Guidelines P/opioids/Pages/Prescribing-Guidelines.aspx PA Opioid Centers of Excellence m PA Department of Health- Prescription Drug Monitoring Program Health/Offices%20and%20Bureaus/PaPrescriptionDrugMonitoringProgram/Page s/a/clinicalresources.aspx

29 Final Message We don t want to co-manage your patients You play a critical role in fighting the opioid epidemic You must prescribe in a manner consistent with standard of care We want to partner with you to ensure your patients/our members are receiving medically necessary, safe, and effective care

30 Useful Resources CDC otal_daily_dose-a.pdf Prescriber s Letter Comparison-Chart-Prescriber-Letter-2012.pdf

31 Useful Resources line.html %20Use%20of%20Opioids%20t J. Aro1

32 Slide 31 J. Aro1 this link doesn't work. what is it? Aro, Jennifer, 11/6/2017

33 Questions? Q&A