Confronting the opioid epidemic

Opioid abuse is a major public health crisis in America and is only growing in our state.

Working with our members, providers, and pharmacists, AmeriHealth has taken several steps to help confront the opioid epidemic.

Removing barriers for members

  • AmeriHealth has removed member cost-share, after their deductible is met, for injectable and nasal spray formulations of naloxone and Narcan, which is a brand of naloxone. Naloxone blocks the effects of opioids and reverses an overdose when administered in time.
  • We cover comprehensive treatment services for members dealing with an opioid abuse disorder. For instance:
    • We offer access to a full range of inpatient and outpatient treatment options, including inpatient hospital units, outpatient units, and residential facilities
    • We do not put limits on visits to detoxification facilities
    • We cover methadone treatment with in-network providers
  • Because medication-assisted treatments (MATs) have proven to be effective in managing opioid dependence, there are no prior authorization requirements needed to start therapy for Vivitrol® and Suboxone®, two of the most common MATs.

Please note: All drugs obtained through AmeriHealth’s Direct Ship Drug Program do require prior authorization. Prior authorization is required for greater than six months of continuous treatment with Suboxone®. View our opioid policy.

Supporting providers

We work closely with our network providers to give them the tools, information and resources they need to care for their patients who are prescribed opioids, including:

  • A comprehensive portfolio of online opioid awareness tools and resources.
  • Ongoing communications and education regarding the Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids.

Working with physicians

Opioid addiction often starts from the abuse of a prescription medication. To help prevent the potential abuse and misuse of opioid medications, AmeriHealth has policies in place to manage and monitor members’ opioid prescription usage, including:

  • Supply limits which are a cumulative supply limit of two five-days’ supply, per 60 days for short-acting opioids. Prior authorization applies if a member requires greater than two five-days’ supply within the 60-day timeframe.
  • Prior authorization is required for all long-acting opioids, short-acting opioids prescribed for long-term use and opioid-containing patches.
  • The cumulative daily limit of 90 morphine milligram equivalents (MME) is applied across all opioids. MME is a number that is used to determine and compare the potency of opioid medications. It helps to identify when additional caution is needed. The limit is calculated based on the number of opioid drugs, their potencies and the total daily use. For members whose opioid dose exceeds 90 MME/day, prior authorization is required.
  • The pharmacy system alerts the dispensing pharmacists through claim messages or claim rejections when a member:
    • Fills a benzodiazepine and opioid medication within 30 days of each other
    • Fills a skeletal muscle relaxant and opioid medication within 30 days of each other
    • Fills an opioid prescription after receiving medication assisted treatment