5 Things to Know about the Recent Opioid Regulations for Medicare Part D

In June, the House of Representatives passed legislation that will impact the already complex Medicare Part D requirements. Spurred in part by a Department of Health and Human Services report that showed one-third of Medicare Part D beneficiaries received an opioid prescription in 2016. For the approximately 13 million people enrolled in Part D, nearly 80 million opioid prescriptions were written. More than 501,000 people received “high” amounts of opioids and 69,563 received “extreme” amounts, some as a result of doctor shopping (a practice through which individuals obtain medically unnecessary prescriptions from multiple pharmacies and providers). These prescriptions cost the program more than $4 billion.

Here are 5 things you should know about the Preventing Addiction for Susceptible Seniors (PASS) Act of 2018, sponsored by Rep. Peter Roskam (R – IL), chairman of the House Ways and Means Health Subcommittee.

• Electronic Prior Authorizations (ePA). ePA is intended to streamline and expedite the process of verifying a certain medication is covered by the Part D plan. Consumers have choices in the Medicare plans they select, but all plans must cover the same categories of drugs. However, generally plans can dictate which specific drugs are covered in each drug category. ePA allows a provider to electronically query the individual’s plan for a specific drug, and access information on coverage, co-payments and other authorization information. Receiving this information prior to prescribing or providing services can help prevent waste, fraud and abuse.
• Drug Management Programs. A requirement for Part D is to provide drug management programs for Medicare beneficiaries that might be at risk for prescription drug abuse. Previously this was allowed on the Part D plan, but not required.
• Medication Therapy Management Programs. This legislation expands medication therapy management programs to include beneficiaries who are at risk for prescription drug abuse.
• Improved “High Prescribers” Monitoring. The legislation calls for at least an annual information push to “high prescribers” about the proper prescribing methods (excluding hospice and oncology providers).
• Information Portal. Establishes a secure portal to exchange information about fraud, waste and abuse among providers and suppliers.

The overall goal of this legislation is to prevent the overuse of opioids through education and the use of technology to monitor usage to make it easier for prescribers to ensure that the consumers they are serving are properly adhering to their prescribed pain medications.