Prescription opioids: What you need to know
Providence Medicare Advantage Plans is committed to keeping you safe and healthy. Even if you’ve never taken opioid pain medications, the following information may help you better understand them. And if the need ever comes up for you, you’ll also find tips on working with your doctor to help ensure safe use.
Prescription opioids are a group of drugs used to reduce moderate to severe pain. Common types of prescription opioids are oxycodone, hydrocodone/acetaminophen and morphine. While opioids can be helpful in relieving certain types of pain, they also come with serious risks and complications. Taking opioid medications, especially for longer periods of time, even as directed, may:
- Cause side effects like stomach upset, constipation, confusion, dizziness, depression, drowsiness and an increase in pain sensitivity.
- Lead to tolerance, which means you might need to take more of a medication for the same pain relief.
- Create physical dependence where you may suffer withdrawal symptoms (such as anxiety, nausea and vomiting) when the medication is stopped.
- Lead to serious risk of addiction and overdose. An opioid overdose, often marked by slowed breathing, can cause sudden death. This risk may be increased if opioids are taken with alcohol and other medications (such as muscle relaxants and medications for anxiety and sleep).
Given the risks associated with opioids, non-opioid therapy should be considered first. In many cases non-opioid therapy may be more effective than opioids. Examples of non-opioid therapy include:
- Pain relievers like ibuprofen, naproxen or acetaminophen
- Medications that may help with nerve type pain (such as gabapentin or duloxetine)
- Heat or ice, massage, acupuncture, physical therapy and exercise
Opioid therapy should be started only if the expected benefits are anticipated to outweigh risks. It is important that you have a discussion with your provider before starting these medications.
If your provider decides that opioids are necessary for you, here are a few ways to help avoid misuse:
- As with all medications, only take the medications as directed.
- Talk with your provider if you have concerns about side effects, including dependence.
- Do not drink alcohol while taking opioids.
- Check with your provider or pharmacist to make sure it’s okay to take opioids with other medications you are taking.
- Store all medicines in a secure place that’s out of the reach of children and others.
- Never share pain relievers with other people.
- Follow up regularly with your doctor about your care.
- Properly dispose of any unused medications. The following guidance may be helpful: https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html
Medicare Part D opioid policies
The Centers for Medicare & Medicaid Services (CMS) implemented a new regulation for opioid prescriptions beginning January 2019. This regulation was developed in an effort to promote safe use of prescription opioids. Providence Medicare Advantage Plans continues to maintain the Centers for Medicare and Medicaid Service's (CMS) opioid prescribing policies that impact Medicare Part D members.
Safety reviews for opioid prescriptions
Providence Medicare Advantage Plans and your pharmacist will do safety reviews of your opioid pain medications when you fill a prescription. These reviews are especially important if you have more than one doctor who prescribes these drugs. In some cases, your pharmacist may need to first talk to your doctor or your doctor may need to submit additional information to Providence Medicare Advantage Plans.
Your drug plan or pharmacist may do a safety review for:
- Potentially unsafe opioid amounts.
- If you take opioids with benzodiazepines like Xanax®, Valium®, and Klonopin®.
- If you take more than one long-acting opioid like Xtampza® and Fentanyl® patches.
- Opioid use: Medicare Part D plans are required to implement a safety edit to limit initial opioid dispensing to a 7-day supply or less. It is important to know that your first prescription will be limited to a 7-day supply or less. This does not apply to you if you already take opioids.
If your pharmacy can’t fill your prescription as written, including the full amount on the prescription, your pharmacist will give you a notice explaining how you or your doctor can contact us to ask for a coverage decision. You can also visit our Pharmacy Medicare Part D Coverage Determinations, Exceptions, Appeals and Grievance page for more information on how to request a coverage decision. If your health requires it, you can ask us for a fast coverage decision. You may also ask us for an exception to our rules before you go to the pharmacy, so you’ll know if we will cover the medication.
Drug Management Programs (DMPs)
Part D plans are now implementing Drug Management Programs (DMPs). DMPs help coordinate care for patients who get opioids from multiple doctors or pharmacies and may limit access to certain controlled substances defined as “frequently abused drugs,” such as opioids and benzodiazepines. Providence Medicare Advantage Plans has a DMP for opioids. If you get opioids from multiple doctors or pharmacies, we may talk with your doctors to see if there is concern around the safety of the opioids and benzodiazepines prescribed. If there are safety concerns, we may discuss alternative options with your doctor to help better manage your pain and coverage of opioids may be limited. For example, under the DMP you may need to get these medications only from certain doctors or pharmacies to better coordinate your health care.
Before any limitations are placed, we will notify you by letter. You’ll be able to tell us which doctors or pharmacies you prefer to use to get your prescription opioids and benzodiazepines. After you’ve had the opportunity to respond, we will send you another letter confirming whether or not coverage will be limited. You and your doctor can appeal if you disagree or think we made a mistake. The second letter will tell you how to contact us to make an appeal.
Note: The safety reviews and DMPs should not apply to you if you have cancer, get hospice, palliative, or end-of-life care, or if you live in a long-term care facility.
If you would like more information regarding the DMP or have questions, please contact the Providence Medicare Advantage Plans Pharmacy Department at 503-574-7400 or 877-216-3644, 8 a.m. to 6 p.m. (Pacific Time), Monday through Friday. TTY users should call 711.
Other resources include:
- “Your Guide to Medicare Prescription Drug Coverage” at: www.Medicare.gov/publications
- “How Medicare Drug Plans use Pharmacies, Formularies, & Common Coverage Rules” at: https://www.medicare.gov/Pubs/pdf/11136-Pharmacies-Formularies-Coverage-Rules.pdf
- Call the State Health Insurance Assistance Program (SHIP). Visit www.shiptacenter.org or call 1-800-MEDICARE for the phone number of your SHIP.
- For resources and information about the National Opioid Crisis, go to: www.hhs.gov/opioids or the Center for Disease Control (CDC) at: https://www.cdc.gov/drugoverdose/epidemic/index.html
- For more information on what Medicare covers and drug coverage rules, visit Medicare.gov. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.