HEALTH CARE AUTHORITY
[Filed August 27, 2019, 7:30 a.m.]
Title or Subject: Medicaid State Plan Amendment (SPA) 19-0014.
Effective Date: January 1, 2020.
Description: Pharmacy update - Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) requirements.
The health care authority (the agency) intends to submit SPA 19-0014 to implement requirements of medicaid under Section 1004 of SUPPORT Act (the act). To comply with the act, the agency will submit the following changes to the state plan:
1. Description of the agency's opioid policy regarding quantity limits for acute prescribing, prescriber attestation requirements for chronic use, and changes to comply with the act. These limits, related exemptions, and attestation requirements have been in place since November 2017. This SPA will include a new morphine milligram equivalent (MME) limitation as required by the act, which will be incorporated into the existing attestation process.
2. Descriptions of existing policies related to rejecting duplicate prescriptions and monitoring for prescriptions refilled earlier than medically necessary.
3. Automated processes for claims review to:
|•||Indicate when an individual is prescribed a subsequent fill of opioids in excess of the limitations above;|
|•||Indicate when an individual is prescribed greater than a one hundred twenty MME dose of opioids per day; or|
|•||Monitor when an individual is concurrently prescribed opioids and benzodiazepines or opioids and antipsychotics.|
4. Description of the program the state has in place to identify fraud and abuse related to opioids and what the agency does when fraud or abuse is identified. Description of the agency's program for monitoring antipsychotic use in children, as expanded to comply with the act. Currently, the agency has specific age and dose thresholds for antipsychotic medications, beyond which a consultation with an agency-designated pediatric mental health specialist is required. Under the act, the agency will add an automated claims review process to monitor the prescribing of antipsychotics for all children, regardless of whether these age and dose thresholds are exceeded.
5. Provision that affirms the agency has updated its contracts with managed care organizations (MCO) to require MCOs to participate in and implement all of the same activities described above.
SPA 19-0014 is expected to have no effect on the annual aggregate expense/payments for prescription drugs.
SPA 19-0014 is in the development process; therefore a copy is not yet available for review. The agency would appreciate any input or concerns regarding this SPA. To request a copy when it becomes available or submit comments, you may contact Charles Agte, Prescription Drug Program, 626 8th Avenue S.E., Olympia, WA 98504, phone 360-725-1301, TTY 711, email Charles.Agte@hca.wa.gov, web site https://www.hca.wa.gov/billers-providers-partners/programs-and-services/pharmacy (please note that all comments are subject to public review and disclosure, as are the names of those who comment).