The North Carolina Department of Health and Human Services (DHHS) today announced additional measures to fight the opioid epidemic, recognizing the important role of health care payers in combating opioid use and misuse. Medicaid, which provides health insurance to about 2 million North Carolinians, will now require prior approvals for certain opioid doses. And, DHHS has established a Payers’ Council to bring together health care payers across the state to partner on benefit design, member services, and pharmacy policies to reduce opioid misuse and overdose.

These actions support North Carolina’s Opioid Action Plan, which was unveiled earlier this summer by Governor Roy Cooper and DHHS Secretary Mandy Cohen, M.D., and includes comprehensive strategies specific to North Carolina. It was prepared in collaboration with community partners to address the complex causes and outcomes of the opioid crisis.

“We look forward to working together to address the opioid epidemic by examining our pharmacy policies and taking steps to improve access to alternative effective pain control modalities and medications,” said Secretary Cohen. “Bringing payers together to promote policies around opioid prescribing, pain management, and treatment and recovery services is an integral part of our work with many partners to address this crisis.”

Details of the safe prescribing policies and Payers’ Council measures are listed below.

Safe Prescribing Policies. Effective yesterday, DHHS set new policies for Medicaid prescriptions for opioids and benzodiazepines. Prior approval is now required for opioid analgesic doses that: 

Exceed 120 mg of morphine equivalents per day;

Are greater than a 14-day supply of any opioid; or

Are non-preferred opioid products on the North Carolina Medicaid Preferred Drug List.

There are two exceptions to the prior approval requirements:

Beneficiaries with a diagnosis of pain secondary to cancer are exempt from prior authorizations,

Per federal law, pharmacies may dispense a 72-hour emergency supply to Medicaid beneficiaries for drugs requiring prior authorization.

These policies apply to the Medicaid and NC Health Choice programs and build on provisions of the NC Controlled Substance Reporting System and the recently passed Session Law 2017-74 Strengthen Opioid Misuse Prevention (STOP) Act.

North Carolina also has recently released a proposed program design for Medicaid transformation, which lays out the potential initiatives to combat the opioid epidemic. Specifically, DHHS is taking comments on proposals to expand the array of substance use disorders; strengthen pain management treatment capacity; enhance provider education for prescribing and managing chronic pain; provide care coordination for chronic pain beneficiaries; increase access to substance use disorder services through Carolina Cares legislation; eliminate prior authorization for an initial prescription of suboxone; and other proposed initiatives.

In addition, DHHS is bringing claims payers together.

North Carolina Payers’ Council. Claims payers, such as health insurance companies and workers’ compensation insurers, are uniquely positioned to address the opioid crisis, while also acknowledging the pain and health management needs of providers and their patients.

The N.C. Payers’ Council is being assembled by DHHS and will bring together large health payers in North Carolina to identify prescription drug and clinical benefits policies, and treatment and recovery support. Payers participating in the Council include the State Health Plan; Medicaid; Palmetto GBA as the Jurisdiction M Medicare Administrative Contractor for North Carolina; Blue Cross and Blue Shield of North Carolina; UnitedHealthcare; Aetna; Cigna and several workers’ compensation insurers.

Once assembled, the Payers’ Council will work to identify, align and implement policies to improve health outcomes by:

Supporting providers in judicious prescribing of opioids;

Promoting safer and more comprehensive alternatives to pain management;

Improving access to naloxone, substance use disorder treatment and recovery supports; and

Engaging and empowering patients in the management of their health.



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