Opioid Dependence Dose Edit Reminder

On Oct. 1, 2018, a maximum daily dose edit for opioid dependence treatment medications was implemented. A pharmacist may override the edit at point-of-sale after consulting the prescriber to determine the clinical need for the higher dose. Documentation is to be made in the NCPDP pharmacy system or on the original prescription. Bypassing the edit requires an override (submission clarification code 10) that should be used by the pharmacist when the prescriber provides clinical rationale for the therapy issue alerted by the edit. A prescriber may proactively document the clinical rationale with issuance of the prescription. The concise documentation may provide information about the patient’s situation, history, therapy goals and outcome. Documentation solely of a diagnosis code is not legitimate justification. The adequacy of proactive documentation is the professional judgement of the pharmacist.

Questions can be directed to the GDIT Call Center at 866-246-8505. GDIT cannot override the claim on behalf of the pharmacy or the prescriber. Additionally, clinical rationale should be provided to the beneficiary’s dispensing pharmacy and not GDIT.

[From the September 2018 Medicaid Pharmacy Newsletter]