Reminder: Changes to MaineCare Benefits Manual (MCBM) Section 80, Pharmacy Services
January 2, 2013
REMINDER: CHANGES TO MAINECARE BENEFITS MANUAL (MCBM) SECTION 80, PHARMACY SERVICES As a reminder, certain changes to MCBM Section 80, Pharmacy Services are effective on January 1, 2013.
Limits to Opioid Coverage Opioid medication such as Vicodin, oxycodone, hydrocodone, and fentanyl are used to treat pain. MaineCare’s coverage of opioids for pain will have new limits. If your patient has new pain, and opioids are allowed, you will only be able to prescribe them for fifteen (15) days each year. If the patient needs more than 15 days of opioid treatment, you will need to receive Prior Authorization (PA) from MaineCare.
If you believe opioids are medically necessary and the PA request is approved, there will be a maximum allowed dose of the medication. The patient may be required to get a second medical opinion or try another treatment for pain, when appropriate.
If you believe a patient does not need opioids, or if the PA request is denied, you and your patient will need to work together on a new treatment plan. If MaineCare denies the PA request, you will receive a copy of the letter sent to your patient. Although pain medications will have new limits, additional services for treating pain, such as coverage of additional Physical Therapy treatments may be covered by MaineCare. Policy changes on the new limits will begin in early 2013. More information will be provided once available.
Limits to Suboxone/Subutex Coverage Suboxone, Subutex, and their generics are medications used to treat opioid addiction. MaineCare members will have a 24 month lifetime limit for these medications. If it is medically necessary for your patient to continue use of these medications for more than 24 months, then you will need to get PA from MaineCare. You will receive notice from MaineCare about patients who are close to reaching their 24 month limit. You should talk with your patient about the best treatment plan for him/her.
If the patient is beginning Suboxone treatment after January 1, 2013, you and your patient should plan to limit the use of these medications to 24 months or less. If you have a patient currently being treated with Suboxone, you and your patient should plan how he/she can transition off the medication. If your patient has completed 24 months of treatment and you believe it is medically necessary for him/her to continue treatment, you may submit a PA request to MaineCare. If you have patients that have been prescribed Suboxone for 24 months by January 1, 2013, you will need PA for them to continue with the medication by January 1, 2013.
Limits to Methadone Coverage Methadone is a medication used to treat opioid addiction. MaineCare members will have a 24 month lifetime limit for this medication. If it is medically necessary for your patient to continue with the medication for more than 24 months, then you will need to get PA from MaineCare. You will receive notice from MaineCare about patients who are close to reaching their 24 month limit. You should talk with your patient about the best treatment plan for him/her. MaineCare will start the 24 month count of methadone treatment for your patients beginning in January 2013. The earliest a patient will reach the 24 months of covered treatment is December 2014.
Important: The above pharmacy changes will not apply to those with HIV/AIDS, cancer, and other special conditions. There will be no new limits for people who are in a hospital, nursing home or in hospice care. Also, if a patient has both Medicare and MaineCare the changes may not affect him/her. In all cases, the limits will not apply if treatment is medically necessary and you receive PA to prescribe the medication.