Call us at: 1-866-473-0471 (TRS 711), 8 a.m. to 6 p.m., Monday–Friday
Providers call: 1-866-275-3247

Opioid management program for Medicaid/MassHealth ACO plans 

Effective April 1, 2023, Fallon Health ACO plans will begin to follow the MassHealth Unified Formulary. All Massachusetts Medicaid managed care organizations (MCOs) will follow MassHealth’s pharmacy drug coverage and criteria. ACOs are however allowed to have different dose thresholds for opioid dosages.

Please refer to the table below for Fallon Health ACO initiatives, thresholds and dose limits.

Edit

Summary

Drug-drug interaction

Soft edit: drug-drug interaction between opioids and benzodiazepines

Drug-drug interaction

Soft edit: concurrent use of opioids and medication assisted treatment for addiction (MAT)

Drug-drug interaction

Soft edit: concurrent use of opioids and prenatal vitamins will trigger soft edit reject

Drug-drug interaction

Soft edit: concurrent use of opioids and antipsychotics will trigger soft reject edit

180 MME limit for Opioid regimens

Prior authorization will be required if a member’s opioid regimen exceeds 180 MME/day. Members with sickle cell disease, cancer, or a history of a diagnosis indicating palliative care treatment are exempt.

7 day supply initial fill

Treatment naïve member (no opiate claims in the last 120 days) will have a soft reject if attempting to fill > 7 day supply.  Members with sickle cell disease, cancer, or a history of a diagnosis indicating palliative care treatment are exempt.

Duplicate Long-Acting Opioids

For any combination of 2 or more long-acting opioids, if there is greater than 2 months of duplicate claims in a member’s claims history the opioid will require prior authorization

Duplicate Short-acting Opioids

For any combination of 2 or more short-acting opioids, powders, and combination products, if there is greater than 2 months of duplicate claims in a member’s claim’s history

Concurrent Therapy with Opioid Dependence Agents

Prior authorization is required if a member is stable on any buprenorphine product used for substance use disorder and is attempting to fill a long-acting opioid (for any length of time), a short-acting opioid for more than a 7 day supply, or short-acting opioid(s) for more than 7 days of therapy in the last 30 days.
“Stability” is defined as: 1. Buprenorphine/naloxone film or tablet, Zubsolv, or Bunavail: 60 days of therapy within the last 90 days 2. Probuphine (buprenorphine implant): history in the past 210 days. 3. Sublocade: ≥ 56 days of therapy in the last 84 days

Quantity Limit & Quantity limit for short acting opioids without long acting opioids

Claims for specified short-acting opioids over a dosage limit (120MME) and being used as monotherapy (no claim for a long acting opioid agent within the last 30 days) will reject at the pharmacy as prior authorization required.

Concurrent Opioid and Benzodiazepines

Hard Edit: Drug – 60 day overlap of opioid and benzo within last 90 days; one-way edit where only benzo will reject.

Therapeutic Dose

Hard Reject: Cumulative acetaminophen dose check (APAP); > 4 gram of acetaminophen containing products will trigger a hard reject edit

Therapeutic Dose

Hard Reject: Cumulative dose check of aspirin (>4GM) and ibuprofen (>3.2GM).

Concurrent Therapy

Concurrent use of opioids and MAT (medication assisted treatment for addiction); opioid post MAT (e.g. Suboxone) will trigger soft reject edit

 

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Cost and eligibility

There’s no cost to join Fallon Health-Atrius Health Care Collaborative. You must qualify for MassHealth and live in one of the cities or towns in our service area.

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Have questions? You can call us  at 1-866-473-0471 (TRS 711), from 8 a.m. to 6 p.m., Monday – Friday.

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