Colorado Medicaid to Tighten Opioid Usage Policy

Posted: July 12, 2017

In a continued effort to address the growing opioid epidemic in Colorado, today the Department of Health Care Policy and Financing (Department) announced it is tightening its policy on prescribing and dispensing opioid pain medications to Health First Colorado (Colorado’s Medicaid program) members. The new policy will be implemented in two phases.

The first phase is effective August 1, 2017 and limits the supply of opioids to members who haven’t had an opioid prescription in the past 12 months.

The policy was developed following a Department analysis of claims data showing a growing number of Health First Colorado members who have not taken opioids before – or have not taken them for up to one year – once they start opioids go on to using them more frequently. The Department wants to ensure members have appropriate medication to treat their pain, without excessive doses that are not needed. The new policy will allow:

• A 7-day supply to be filled initially,
• Two additional 7-day refills, but a fourth refill request will require providers to obtain prior authorization from the Department.
• The fourth request could also require a consultation with a pain management physician from the Department’s Drug Utilization Review board.

Under current policy, Health First Colorado members are allowed up to a 30-day initial supply with subsequent fills as prescribed by their doctor.

“The goal of this new policy is twofold,” said Dr. Judy Zerzan, chief medical officer for the Department. “First, to reduce the number of Medicaid members who might develop an addiction to opioids when it could be prevented. Second, to reduce the amount of excess opioid pills in the community.”

The second phase of the policy will reduce the daily Morphine Milligram Equivalents (MME) for members currently on a pain management regimen. Beginning October 1, 2017, the total daily limit of MME will be decreasing from 300 MME per day, to 250 MME per day.

• Under the new policy, a prescription that puts the member above 250 MME per day will be rejected and require a prior authorization. In some circumstances, a consultation with the Department’s pain management physician may be required.

“I think all the steps that we can take within reasonable parameters are important and should be taken,” said Dr. Alex Reish, pain management specialist and Drug Utilization Review board member. “It's encouraging to see the progress that has been made with the previous policies and I think this new opioid policy will be important and necessary as well.”

The Department is recommending that providers and their teams begin tapering Medicaid members to or below the 250 MME per day threshold prior to October 1, 2017. The new 250 MME limit will not apply to members in palliative or hospice care, nor those being treated for cancer.

About the Colorado Department of Health Care Policy and Financing: The Department administers Health First Colorado (Colorado's Medicaid Program) and Child Health Plan Plus as well as a variety of other programs for Coloradans who qualify. For more information about the Department, please visit Colorado.gov/hcpf.