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Texas Medicaid Proposes New Opioid Limits

November 7, 2018

The Texas Medicaid Vendor Drug Program has proposed a policy that would apply morphine equivalent dose (MED) limits per day and seven-day limits on opioids opioids that are used to treat acute pain in the state’s Medicaid managed care organizations (MCOs).

The Texas Health and Human Services Commission (HHSC) is accepting comments until November 14, 2018.

The following is the draft policy:


Substance use disorder for many, start after initially receiving opioid prescriptions for an episode of acute pain. In an effort to encourage appropriate use and reduce opioid over prescribing, MCOs must adhere to the requirements listed in the sections below.

A. Morphine Equivalent Dose and Day’s Supply Limits

Morphine equivalent dose (MED) per day is used to describe the potency of one opioid to another for comparison. MED per day recommendations vary depending on clients’ prior history of opioid use. Additionally, CDC recommends to start opioid treatment with an immediate-release/short-acting (IR/SR) formulation at the lowest effective dose, instead of an extended-release/ long-acting (ER, LA) formulation.  Prescribing opioids for treatment of acute pain is rarely needed for more than seven days. Opioid prescriptions will be limited to a maximum of seven days for opioid naïve clients. This limitation is intended to reduce the risks of addiction or diversion of unused opioids.

With the exception of members who are receiving hospice care or palliative care, treatment for cancer, individuals who are residents of facilities who dispense drugs through a single pharmacy, or other individuals the state elects to exempt, MCOs must implement the policies listed below.

  1. Opioid naïve is defined as members who have taken opioids for a duration less than or equal to (≤) seven days in the prior 45 day period. For opioid naïve patients, the MCOs must require authorization for:

    a. An opioid prescription if the day supply exceeds seven days.

    b. A prescription for a long-acting opioid formulation.

    c. A claim with the total daily dose of opioids exceeds 90 MED.

    d. Duration of prior authorization approval may not extend beyond the days’ supply of the claim.

  2. For members who no longer meet the definition of opioid naïve, an authorization will be required if the total daily dose of opioids exceeds 90 MED.

B. Retrospective Reviews

MCOs must perform annual retrospective drug utilization reviews on opioid overutilization to monitor prescribers for outlier activities. If the MCO identifies outlier prescribing patterns, then the MCO must conduct a review and, if necessary, an intervention, such as a letter or phone call to the prescriber or a peer-to-peer review between the prescriber and the MCO.

C. Clinical Prior Authorization

HHSC has clinical prior authorization criteria approved by the Drug Utilization Review (DUR) Board related to opioid utilization. MCOs may choose to implement any of the approved criteria listed on the Vendor Drug Website.