Medicare pharmacy and prescriber home starts January 2019

Per guidance established by the Comprehensive Addiction and Recovery Act of 2016, the Centers for Medicare & Medicaid Services has established provisions to develop a pharmacy and prescriber home program for opioid medications.

 

Beginning January 1, 2019, Anthem will work with beneficiaries and providers to help to reduce the risk of opioid dependency by streamlining access to opioid medications.  If a beneficiary is exhibiting at-risk opioid medication utilization, the plan sponsor will work with the beneficiary and provider to select a pharmacy home and prescriber home for the beneficiary’s opioid medications.

 

At risk is defined by CMS as:

1. Greater than 90 mg per day cumulative morphine milligram equivalent (MME)
2. Greater than three (3) opioid prescribers and greater than three (3) opioid dispensing pharmacies, or
3. Greater than five (5) opioid prescribers, regardless of the number of pharmacies

 

Please note:

• Cancer, LTC and Hospice are exempt
• Beneficiaries will have the choice of which pharmacy or prescriber to select as their home.
• Plan sponsors will request agreement from the provider selected as the home.
• At this time, only opioid and benzodiazepine medications will be delegated to a home pharmacy or prescriber.
• Both beneficiaries and providers will receive letters to explain what is happening and how it will happen.
• Beneficiaries retain the right to request a coverage determination and may choose to change their Home pharmacy or prescriber at any time.