Medicare New Opioid Rule Starting January 1st

The following has been compiled by The Alliance for the Treatment of Intractable Pain (ATIP) for chronic pain patients to navigate the new Medicare opioid prescribing rules coming January 1, 2018, in the United States. I hope this helps the people that will be affected to not have interruptions in their opioid prescriptions. Please pass this information on to others that may be affected.

Much Love & Many Prayers,

From The Alliance for the Treatment of Intractable Pain:
This January, changes to opioid and other controlled prescription medications will occur as CMS (Medicaid/Medicare), and many private insurers begin implementing the CMS Final Call Rules.

Opioid/controlled prescription coverage issues are summarized here:

CMS expects sponsors to implement the following formulary-level opioid safety edits (opioid safety edits) at the point-of-sale (POS) in 2019:

1. Soft edit for concurrent opioid and benzodiazepine use
2. Soft edit for more than one long-acting (LA) opioid
3. Care coordination (soft) edit at 90-199 morphine milligram equivalents (MME)
4. Hard edit at 200 MME or more
5. Hard edit 7 day supply limit for initial opioid fills for opioid naïve patients

IF you are under 90MME, and are not taking concurrent benzodiazepines or other “potentiators”, this should not affect your coverage.

IF you are between 90-199MME, a one-time soft edit on the part of the pharmacist will be required. If you have only one prescriber and use one pharmacy, then you should only need this safety edit once per year.

IF you are at 200MME or over, you will need to find out from your insurer if they will cover your medications at your MME.

A soft edit requires the pharmacist to contact the prescriber to confirm intent. If it is confirmed, the pharmacist will enter a code to override the edit and fill the prescriptions. A soft edit can be resolved at the POS.

A hard edit requires the pharmacist to contact the insurer (or sponsor) to determine if they will cover the prescriptions. Hard edits are not resolvable at the POS, which is why ATIP encourages all patients to consider the following information to help determine your coverage for next year and take action to hopefully prevent disruptions in your prescription coverage in January.


From CMS: “Part D sponsors are expected to develop specifications that exclude beneficiaries who are residents of a long-term care facility, in hospice care or receiving palliative or end-of-life care, or being treated for active cancer-related pain from all of the opioid safety edits. Sponsors should use all information available to them to reasonably exclude these beneficiaries from triggering the edits at POS in the first place.”

Sponsors should also apply specifications to account for known exceptions, such as, high-dose opioid usage previously determined to be medically necessary such as through coverage determinations, prior authorization, case management, or appeal processes.


Below are steps you can take to evaluate and/or maintain your prescription medication coverage for next year:

1. Know exactly which opioid medication(s) you are on and at what dose.

2. Know how many MME’s you take per day.

(To determine your MME, please visit:
Select “opioid conversion calculator” to convert any opioids to oral morphine, with thanks to Dr. Jeff Fudin)

3. Know if any of your opioid pain medications will require a Prior Authorization, and if so, have that done now.

4. Consider asking your provider if the codes for Palliative Care could be added to your chart/prescriptions, if your provider thinks you might qualify for treatment under the Palliative Care exemption. The general code for Palliative Care is Z51.

4. Have a conversation with your clinician(s) and ask if they are aware of these upcoming Rules, and if not, share the links provided below with them.

5. If you don’t have a prior authorization, ask for a “coverage determination” from your insurer (CMS calls them “sponsors.”) This will require you to know your medications and MME’s. With that information, you can ask your sponsor:

“I am requesting a coverage determination. I take xxx & zzz opioid/benzodiazepine/potentiator medications. Will my medications be covered? If you don’t know, may I speak with a supervisor who does know?”

Then use that information to work with your clinicians and your pharmacy.

If you experience a denial of coverage, you have a few options:

Ask your clinician to schedule a clinical care conference with your insurer to explain why you need certain medications.
Ask your clinician if they will arrange a peer-to-peer conference with a clinician from the insurer to explain your medical necessity.
If denied, ask your provider to get the name and license # of the physician who denied your coverage
Use all the information you collected to file an appeal with CMS, either on your own or with the help of a loved one or patient advocate.

Helpful links:

• For additional information regarding the final 2019 Medicare Parts C&D Call Letter, please visit

• For additional information regarding the 2019 Part C and D Regulation (CMS-4182-F), please visit

• For information on Medicare Prescription Drug Appeals and Grievances, visit

• For additional information regarding the CDC Guideline for Prescribing Opioids for Chronic Pain, please visit

• To review the CMS Roadmap to Address the Opioid Epidemic, please visit epidemic-roadmap.pdf.

• To review the Medicare Prescription Drug Coverage and Your Rights, please visit Education/Outreach/Partnerships/downloads/yourrightsfactsheet.pdf.

• Any general questions related to the Medicare Part D opioid over-utilization policy may be sent to

• Questions related to submission of opioid safety edit information should be sent to

10 thoughts on “Medicare New Opioid Rule Starting January 1st

  1. Thank you for sharing this helpful information. I do believe that government should NOT be able to tell a physician what they can prescribe to a patient that lives with chronic pain. Doctors in the states have cracked down on prescriptions, but all that is doing is making it difficult for a person in pain to have any decent quality of life

    Liked by 1 person

    • You’re welcome! I am trying to get it to everyone that I can. The current opioid situation for legitimate chronic pain patients is very scary. Some have been cut off and are losing the will to live because of the decreased quality of life. is like a chronic pain community “facebook.” Every night I talk to atleast 2 people that are saying they don’t think they can go on. It is breaking my heart. That’s why I started my blog. I’m sorry it took so long to reply. I’ll be catching up on reading tonight, but I hope you are doing well tonight and have an awesome weekend!

      Liked by 1 person

      • Thank you so much for sharing your Facebook community. I am definitely going to check it out! Pain is so terrible to live with and gets so much worse when they claim there is an issue with opioids. I think it is all made up by the insane government!

        Liked by 1 person

  2. The US is making opioid legislation based on emotions and not on science at this moment. More research is needed about chronic pain. There are many impressive people that are out there fighting for us. All we can do is pray that some common sense will be woven in this mess of the chronic pain community’s own opioid crisis.


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