A federal plan calling for Medicare Advantage Part D sponsors to deny potentially unsafe pain drugs such as hydrocodone and oxycodone—perhaps to patients who may be "doctor shopping"—has incurred strong objection from the American Medical Association.
The 131-page "advance notice" from the Centers for Medicare and Medicaid Services, which would take effect Jan. 1, 2013, calls for Part D sponsors to employ more effective ongoing and retrospective drug utilization reviews, or layers of formulary management, for each of their enrollees. The goal is to protect them from receiving harmful quantities of any drug, as well as minimize overutilization.
CMS says that overdoses of such drugs can occur when patients get prescriptions for the same or similar opioids from multiple physicians. Drugs that contain the same potentially harmful ingredient, such as acetamenophen, may become harmful, as doses would accumulate in the patient, the letter says.
"We believe that if point-of-sale (POS) safety edits, such as "therapeutic duplication," "maximum dose exceeded," "refill too soon," or quantity limits (QLs) were appropriately implemented, such egregious overutilization can be averted," the agency said. The new policy is outlined in CMS's "Advance Notice of Methodological Changes for Calendar Year (CY) 2013 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2013 Call Letter," published February 17.