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Video instructions and help with filling out and completing cms conditions for coverage
Hello everyone and welcome to today's video there are significant changes coming on January 1st of 2021 for Medicare and Medicaid enrollees these are due to the CMS final call rules regarding opioid and other controlled prescription medication this video is a collaborative effort with a tip in hopes of clarifying some key points and providing a breakdown of the information that's been released before I begin I know news of new policy and/or form can be devastating our greatest power in this situation is in having accurate knowledge prior to the implementation of any policy if we have access to the details of medication reform prior to impact then we are able to prepare for interruption of care in advance we must be our own advocates by being proactive and staying informed we may be able to support our clinicians and their office staff by taking the appropriate care to avoid interruptions CMS expects sponsors to implement both a hard and soft edit at the point of sale it's important to note that only Medicare and Medicaid patients will be affected by these rules however private insurers traditionally adopt most of CMS policies and therefore all chronic pain patients should be aware of these changes the soft edit applies to all prescriptions over 90 mm II and up to 199 mm II the purpose of the soft edit is to place a hold on all pharmacy systems before releasing a prescription between ninety and a hundred and ninety-nine mm II for those of you that don't know mm e stands for milligram equivalent at this point the pharmacist must then call the prescribing physician in order to remove the hold once the prescription has been confirmed the pharmacist will be given a code to override the soft edit and the prescription will be dispensed please note that there are two exceptions for why a soft edit may be performed under the 90mm II threshold one is the presence of a concurrent of benzodiazepine prescription and the other is the presence of more than one long-acting opioid if these two exceptions do not apply to you and you are below the 90mm a threshold then these edits should not affect you the soft edit is said to be rooted in a more comprehensive approach to a patient's medication profile in accordance with this concept pharmacists are required to perform a care coordination review this is to ensure the patients are not receiving multiple control prescriptions from various providers if you are below 200 mme and have only one prescriber and one pharmacist you can expect to see this safety edit performed only once yearly the heart at it applies only to prescriptions greater than 200 Mme for patients above this threshold the insurer now has discretion over that prescription this will allow the individual insurance carriers to set their own policies regarding how and if they will cover any amount over 200 Mme we will not know exact.