Due to decades of prescribing more opioids at higher doses, North Carolina is experiencing an opioid epidemic. From 1999 to 2016 more than 12,000 North Carolinians died from opioid-related overdoses. Three North Carolinians die from an opioid-related overdose every day. This epidemic is devastating families and communities. It is overwhelming medical providers and is straining prevention and treatment efforts. Modifying clinical coverage policies to promote safe opioid prescribing was identified as an essential and significant step to realize the vision of the North Carolina Opioid Action Plan (https://files.nc.gov/ncdhhs/NC Opioid Action Plan 8-22-2017.pdf) to reduce opioid deaths by 20 percent by 2021.
On August 27, 2017, N.C. Medicaid began requiring prior approval (PA) for opioid prescribed 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 N.C. Medicaid Preferred Drug List. N.C. Medicaid worked closely with prescribing physicians and pharmacists to develop the best approach to reduce the oversupply of prescription opioids available for diversion and misuse, promote safe opioid prescribing for patients, and encourage alternative pain management, while minimizing administrative requirements as much as possible.
Effective January 2, 2018, clinical coverage criteria for opioid analgesics were updated to comply with the quantity limits mandated by the Strengthen Opioid Misuse Prevention (STOP) Act, S.L. 2017-74 (https://www.ncleg.net/Sessions/2017/Bills/House/PDF/H243v7.pdf). Prior approval is required for short-acting opioids for greater than a five day supply for acute pain and seven day supply for post-operative acute pain. Prior approval is required for long-acting opioids for greater than a seven day supply.
Effective June 1, 2018, clinical coverage criteria for opioid analgesics will be updated to include prior approval required for a) total daily doses greater than 90 morphine milliequivalents per day (↓ from 120) and b) for Schedule III and IV opioid analgesics (i.e. tramadol) added to schedule II opioids already subject to the clinical criteria.
The prescribing provider may submit prior approval requests to NCTracks through the NCTracks portal or by fax. New opioid analgesic prior approval forms and revised clinical coverage criteria will be available on the NCTracks website. Beneficiaries with diagnosis of pain secondary to cancer will continue to be exempt from prior approval requirements.