Opioid 90 MME/Day Limit – Effective 7/22/2019

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Date: April 18, 2019
To: HPSJ Primary Care Providers, Specialists, Clinics, Pharmacies, and Hospitals
From: Health Plan of San Joaquin Pharmacy Department
Subject: Opioid 90 MME/Day Limit – Effective 7/22/2019
Business: Medi-Cal

To reduce the potential for chronic opioid use or misuse, Health Plan of San Joaquin is implementing a safety limit on opioid prescriptions to a cumulative dosage of < 90 MME/day.

This is based on the CDC recommendation that “Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to =50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to =90 MME/day or carefully justify a decision to titrate dosage to =90 MME/day.”

Effective 7/22/2019, all opioids will be limited to a cumulative total of < 90 MME/day.

NOTE: Prescriptions for patients titrating opioids to doses > or =90 MME/day AND patients currently receiving > or =90 MME/day will require authorization.

  • 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.

Below are CDC tools to help you calculate a patient’s MME: –

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/pharmacyprovider-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. 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 April 18th, 2019 and last modified on April 18th, 2019.