NEW – Opioid 7-Day Supply Limit for Initial Fill

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Date: September 20, 2018
To: Primary Care Providers, Specialists, Clinics, Pharmacies and Hospitals
From: Health Plan of San Joaquin Pharmacy Department
Subject: NEW – Opioid 7-Day Supply Limit for Initial Fill
Business: Medi-Cal

To reduce the potential for chronic opioid use or misuse, Health Plan of San Joaquin is implementing a safety limit on initial opioid prescription fills for the treatment of acute pain to no more than a seven (7) day supply.

This is based on the CDC recommendation: “When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids […] more than seven (7) day will rarely be needed.”

Effective 12/1/2018, all initial fills of opioid prescriptions will be limited to a seven (7) day supply.

Prescriptions for patients newly starting on opioids will not require authorization when using up to a seven (7) day supply. Larger quantities exceeding a seven (7) day supply will require prior authorization. Subsequent fills of short-acting opioids will still be limited to a cumulative quantity of 120 tablets or capsules per 30 days.

Patients with documentation of a terminal illness or receiving palliative care will be exempt from these limits. To ensure appropriate continuation of therapy for patients with terminal illness, please submit a PA with this documentation.

Pharmacies cannot resort to billing the patient for cash according to the Knox Keene Health Care Service Plan Act and the California Code of Regulations. Below are some reminders about alternative options when a claim is rejected by HPSJ for covered benefits:

  1. HPSJ will cover the medication if medically appropriate or suggest a suitable formulary alternative. A prior authorization (PA) should be submitted to initiate the process.
    • To submit a PA: Fill out all fields on the required PA form found at hpsj4.wpengine.com/pharmacy-provider-resources/ (both pages). Attach all clinical information and fax all documents to (209)762-4704.
    • If an alternative is suggested in a PA denial, the pharmacy may contact the provider for a prescription for the alternative.
  2. If the member cannot wait the 24-hour turn-around time for a PA review, use a 3-Day Override.
    • This override should only be used for emergency situations for alleviation of severe pain and/or the treatment of unforeseen medical conditions, which, if not treated immediately, would lead to disability or death.
    • The 3-Day Override Code may only be used once per drug/strength, per 365 days, and billed for only a three-day supply.
    • Please refer to hpsj4.wpengine.com for further information regarding the 3-day override.

If you have questions, please contact our Customer Service Department at (209) 942-6320.

Health Plan of San Joaquin is dedicated to providing all members the best health care available in the most effective and efficient manner. Thank you for being one of our valued partners.

Posted on September 20th, 2018 and last modified on September 28th, 2018.

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