Maryland Medicaid

DUR Opioid Frequently Asked Questions

How were the Maryland Medicaid Managed Care Organizations (MCO) informed of the Maryland Department of Health’s new opioid prescribing policies and recommendations?
Representatives from the Department and all eight HealthChoice managed care organizations jointly developed the Opioid Drug Utilization Review Workgroup to develop the new Maryland Medicaid policy.
Will the Department and all MCOs be implementing similar processes?
The Department’s fee-for-service program and all eight HealthChoice managed care organizations are implementing at least the policies that have been established. However, some managed care organizations have chosen to include additional clinical criteria and opt out of certain exemptions. For more information, please refer to the Managed Care Operational Matrix.
As a provider, where do I go to get prior authorization? Where should I direct questions?
The Managed Care Organization Operational Matrix includes phone and fax numbers for prior authorization, and phone numbers for questions for fee-for-service and each of the eight HealthChoice managed care organizations. Our website also includes Prior Authorization information.
Has there been outreach conducted to other stakeholders that may be impacted by these policies?
Yes. The Department and the eight HealthChoice managed care organization have reached out to providers and patients that may be affected by this policy through various modes of outreach (letters, calls, webinars, panels, etc.).
The Department has also presented or shared these policies with the Maryland Medicaid Advisory Committee, Health Officers, Maryland Hospital Association, all of Maryland’s prescribing boards,  and other health and medical professional entities to provide an overview of the new policies set to launch July 1, 2017.
The Department has also developed a Maryland Medicaid Opioid Drug Utilization Review series of webinars to lay out policies and recommendations determined by the Department and the eight HealthChoice managed care organizations.
While awaiting prior authorization approval, should the Medicaid participant be allowed to pay cash for pain medication in the pharmacy?
No. The Medicaid participant should not be allowed to pay cash for pain medication.
Should pharmacists be looking for or asking for an accompanying prescription for naloxone with any opioid prescription more than 90 MME per day or with other risk factors prior to dispensing?
Yes. However, a prescription for naloxone is not mandatory. The prescriber is required to offer a naloxone prescription to a patient, so there may not be a corresponding prescription.
Will Savella, Cymbalta, and Lyrica still require prior authorization if prescribed for pain?
Cymbalta and Lyrica are covered for all Medicaid participants by the fee-for-service (FFS) program. Savella is covered by each of the HealthChoice managed care organizations with their own prior authorization criteria. The Maryland Medicaid Pharmacy Program website has more information.
Are there any exemptions to the new prior authorization policy?
Yes. Patients receiving opioids as part of cancer or sickle cell anemia pain management treatment are exempt from this process. Those receiving palliative care and patients in hospice or long term care facilities are also exempt.
How will HealthChoice managed care organizations or the Department know if a patient qualifies for an exemption from this policy?
The Department will use claims to identify patients within the fee-for service program that qualify for an exemption. HealthChoice Managed care organizations are developing their own processes. Please check with your managed care organization for additional information.
Why is pregnancy included under provider attestations on the prior authorization form?
The Department would like to ensure that providers consider pregnancy status in their assessment of risks and benefits of prescribing opioids to their patient as risks are often higher with pregnancy. The rate of Neonatal Abstinence Syndrome has been rapidly increasing, and providers need to recognize the additional risk that is present for the baby if a woman is pregnant.  By attesting that the patient is pregnant and the benefits outweigh risks, the provider is attesting that they recognize and have considered the higher risks associated with pregnancy and find that the benefits of the opioid prescription outweigh the risks.
Most providers use an Electronic Health Record for documentation. Will the prior authorization process be electronic or paper-based?
The Department will continue to use the current prior authorization process on the fee-for-service side, which is conducted by fax or phone. HealthChoice managed care organizations are developing their own processes. Please check with your managed care organization for additional information.
Will patients, pharmacies, or providers be notified close to the end of a 6-month prior authorization period?
There is no notification process established for the fee-for-service program. However, please check with your managed care organization as the process may vary.
Where can I find additional information on practice-related questions?
Please refer to appropriate standard of care guidelines.
Where can I get additional information on CRISP & PDMP?
Under this policy, prescribers are required to attest to checking the PDMP for a prior authorization to be processed. The Department has received questions related to the logistics and capabilities around PDMP registration, participation, and systems. The Department’s Opioid DUR Workgroup does not manage the operationalization of the PDMP and encourage individuals to use one of the follow resources for additional information.
Please note: Accordance to Maryland state statute HB437 / Chapter 147, 2016, all licensed pharmacists and practitioners authorized to prescribe Controlled Dangerous Substance (CDS) in Maryland must register for the PDMP by July 1, 2017.