In the Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter issued in April 2018, CMS included guidance related to opioid analgesics to help improve patient safety and reduce the misuse and abuse of opioid analgesics.


Beginning January 1, 2019, all short- and long-acting opioids will reject at the point of sale if they are prescribed for more than seven days. This edit applies to members who do not have a prescription in the previous 60 days. The edit excludes members with cancer and members in hospice.


The regulatory change and specific prescription drug edits are intended to:

  • Lessen the risk of long-term use and addiction potential for those using the medication for acute pain.
  • Promote regular review by prescribers to ensure therapy duration is appropriate for those using the medication for acute pain.
  • Allow pain control for those with intractable pain in the case of cancer.
  • Support and monitor access and remedy the unfortunate effects of overutilized opioids.


For more information, please read the CMS CY 2019 Final Call Letter.

Featured In:
October 2018 Anthem Blue Cross Provider Newsletter - California