Opioid Information

Opioid drugs (“opioids”) have serious risks such as addiction, overdose, and death. ATRIO Health Plans shares The Center for Medicare and Medicaid Services (CMS’s) concern about the opioid epidemic and its impact on our communities. We are committed to a comprehensive strategy to combat this public health emergency. There are several drug management programs, based on CMS regulations, that are in place to prevent and combat opioid overuse. If you are a current member who is taking an opioid medication, you may experience one or more of the following safety edits at the pharmacy when you attempt to receive an opioid prescription.

  • Opioid prescriptions will be monitored for safe dosage levels. If the cumulative amount of one or more of your opioid prescriptions is above the pre-determined safety limit as established by CMS, the prescription will be stopped at the pharmacy for review to make sure that the prescription is medically necessary and appropriate.
  • Opioid prescriptions that are taken together with benzodiazepines prescriptions will be stopped at the pharmacy for review to make sure that the prescriptions are medically necessary and appropriate.
  • Members who have not been dispensed a prescription for an opioid within the last 60 days will be limited to no more than a seven-day supply for their opioid prescription for the treatment of acute pain.
  • Prescriptions for Long-Acting Opioids that are taken at the same time will be stopped at the pharmacy for review to make sure that the prescriptions are medically necessary and appropriate.

You may be exempt from these drug management programs if you have cancer or sickle cell disease, are currently in hospice care or are currently residing in a long-term care facility.

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Patients and clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-opioid pharmacologic therapy and non-pharmacologic therapy as appropriate.

Non-Opioid Medication Options
  • Acetaminophen (Tylenol)
  • NSAIDs (Ibuprophen, Naproxen, high-dose Aspirin)
  • Anticonvulsants (Neurontin/gabapentin, Lyrica/pregabalin)
  • Antidepressants (Amitriptyline, Sertraline, Duloxetine)
Topical Agents
  • Lidocaine Gel & Patches (Lidoderm)
  • Capsaicin Cream, Lotions & Patches (Capsin, Icy Hot, Therapatch)
  • NSAID Gel & Patches (Diclofen)
Non-Pharmalogical Options
  • Exercise Therapy (e.g., walking, swimming, yoga, free weights, etc.)
  • Cognitive Behavioral Therapy (CBT)

* If opioids are used, nonopioid medication and nonpharmacologic treatment can also be prescribed as appropriate. Treatment combinations should be tailored depending on patient needs, cost, and convenience.

If you or your prescriber want to dispute the opioid safety edits, you or your prescriber should contact ATRIO directly to let us know. ATRIO will treat that dispute as a request that ATRIO cover the opioid medication without applying the safety edit (i.e., your request will be processed as a Coverage Determination). Coverage Determinations related to opioid safety edits will be expedited.

If a dispensing pharmacy does not fill a prescription based on the pharmacist’s clinical judgment or other reasons, ATRIO can assist you in locating a pharmacy that may fill the prescription. We are dedicated to ensuring that our members do not experience a sudden unnecessary interruption in their medication therapy.

Last updated Nov 13, 2023