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Shelley Starkey

CMS Proposes Medicare Changes to Address Opioids

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The Centers for Medicare and Medicaid Services (CMS) has released its proposed changes to Medicare Advantage and Part D plans for 2019, which include a few provisions to combat the opioid crisis. These changes come in reaction to the soaring opioid prescription and substance use disorder rates among Medicare beneficiaries. CMS is accepting public comments through March 5, and will publish its final rule on April 2.


According to CMS, 30 percent of Medicare Part D enrollees used prescription opioids in 2015, and more than 300,000 Medicare beneficiaries have been diagnosed with an opioid use disorder. Multiple government agencies and experts from the private sector have been issuing their recommendations on how to lower these numbers. At a hearing before the House Ways and Means Subcommittee on Oversight, Elizabeth Curda, a Director from the Government Accountability Office (GAO), presented a report with recommendations to expand opioid oversight protocols within Medicare. The GAO report said that CMS’s current risk identification system was not sufficient to identify over-prescribing providers and all consumers at high risk of opioid misuse.

On Tuesday, the House Ways and Means Subcommittee on Health hosted a hearing on “Removing Barriers to Prevent and Treat Opioid Abuse and Dependence in Medicare.” Experts from the pharmaceutical, medical, and insurance industries testified with a handful of recommendations of their own. For example, Dr. Hal Paz, Executive Vice President and Chief Medical Officer of Aetna, Inc., applauded CMS’s newly proposed opioid prescribing limits, but also called for updating privacy regulations and ensuring the success of “locking patients in” to one pharmacy to avoid multiple prescriptions for the same medications.


In light of many recommendations to Congress and the agency itself, CMS proposed wide-scoping changes in its calendar year 2019 Call Letter, to include the following provisions related to opioid prescribing and use:

  • Opioid prescribing limits under Part D: New prescriptions for Medicare Part D recipients will be limited to a seven-day supply with a maximum daily dosage of opioids for acute pain.
  • Preventing multiple prescriptions: Insurance companies will be required to implement new measures to prevent patients from receiving prescriptions for opioid pain relievers from multiple providers.
  • Changes to Overutilization Monitoring System (OMS): Currently, the OMS flags patients that have prescriptions for both opioids and benzodiazepines, a combination that puts individuals at risk of overdose. Under the proposed changes, the OMS would begin to flag other medications that are dangerous to combine with opioids such as gabapentin and pregabalin.

View the full 2019 Advance Notice and Call Letter and learn how to submit comments on CMS’s website.