2019 CareOregon Advantage Opioid Policies

On January 1, 2019, CareOregon Advantage implemented new opioid policies as required by the Centers for Medicare and Medicaid Services (CMS). These policies include the use of safety alerts and drug management programs to improve the identification and management of patients who may be at risk for misuse or abuse of opiates.

There are several different safety alerts, each with a recommended course of action to resolve, as well as several exceptions to keep in mind. CareOregon Pharmacy has resources that can help you. Call us at 503-416-4100 or 800-224-4840, Monday-Friday, 8 a.m. – 5 p.m. Option 3 for Provider, then Option 2 for Pharmacy Staff. After business hours, call 866-325-7344.

It is important to remember that the new opioid policies are not meant to be prescribing limits. Decisions to taper or discontinue opioids are individualized and are between the patient and the prescriber.

Opioid Safety Alerts

The following safety alerts (claim processing rules) designed to prevent unsafe utilization of opioids will be generated at the dispensing pharmacy if certain opioid claim scenarios are present. Claims will reject for the pharmacist so that they can review and resolve prior to dispensing. To resolve claims rejections quickly and to avoid disruption in therapy, prescribers are encouraged to respond to pharmacists’ outreach in a timely manner and to train on-call prescribers as necessary.

There are some exceptions to these safety alerts. These include:

  • Patients residing in long-term care facilities
  • Patients who have elected hospice with our determination that the opiate is not related to the terminal illness
  • Patients receiving palliative care; and
  • Patients being treated for pain who have active cancer

If the claim rejects (one claim can reject for multiple safety alerts) and the rejection cannot be resolved by the dispensing pharmacist – preventing the prescription from being filled as written – the patient will receive a notice from the pharmacy advising that they have a right to request a coverage determination (prior authorization).


COA_Opioid_Safety_Alert_Chart_1-15-19Click on the document icon for complete details on all safety alerts and corresponding prescriber actions.

We recommend that you print this chart for reference and keep it handy.



Drug Management Programs (DMP)

CareOregon Advantage will continue a drug management program that identifies patients who are potentially at-risk for misuse and abuse of opioids and benzodiazepines, and to coordinate care. These are patients with cumulative Morphine Milligram Equivalent (MME) of 90 mg for any duration in the past 6 months and who also have filled prescriptions from either 1) 3+ prescribers and 3+ pharmacies or 2) 5+ prescribers. These patients will be notified and enrolled into case management, which involves outreach to their prescribers. Patients are exempt if they are in long-term care, in hospice, receiving palliative care or have active cancer-related pain.

In 2019, we will have the ability to limit access to these drugs using any of the following options:

  • Requiring the patient to obtain these drugs from a specified prescriber and/or pharmacy, or
  • Implementing an individualized point of sale coverage limit for these types of medications.

Before restrictions are implemented, we will notify the patient and confirm the limitation and duration.

Note: If there is a limitation placed, the patient and their prescriber have the right to appeal.