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Effective, January 1, 2018, Mercy Care Plan and Mercy Maricopa Integrated Care will be implementing changes to the day supply limit for short-acting opioids. Per AMPM Policy 310-V, the current 7-day supply limitation will be changing to a 5-day supply. This change will be operationalized for all areas currently listed in the policy as a 7-day supply; however all of the exceptions and processes to obtain an exception will remain the same and are not affected by this policy change.
Children (<18 years of age)
The initial and refill prescription 5-day supply limitation for short-acting opioid medications does not apply to prescriptions for the following conditions and care instances*:
- Active oncology diagnosis;
- Hospice care;
- End-of-life care (other than hospice);
- Palliative care;
- Children on opioid wean at time of hospital discharge;
- Skilled nursing facility care;
- Traumatic injury, excluding post-surgical procedures;
- Chronic conditions for which the provider has received PA approval through the Contractor; and
- Post-surgical procedures. Initial prescriptions for short acting opioid medications for post-surgical procedures are limited to a supply of no more than 14 days. (Note that refills are limited to no more than 5 days.)
*Conditions and care-instances must be communicated to the pharmacy by documenting on the hard copy prescription or communicating it telephonically, electronically or via fax to the pharmacy. Please refer to Exhibit 310-V-2 - 5-Day Supply Limit of Prescription Opioid Medications Exclusion Specifications under Chapter 300 of the
AHCCCS Medical Policy Manual
, Section, 310, Covered Services, Exhibit 310-V - Prescription Medication-Pharmacy Services for more detailed information.
Adults (18 years of age and older)
The initial prescription only will be limited to a 5-day supply if the member is determined to be opioid naïve. An initial prescription for a short-acting opioid medication is one in which the member has not previously filled any prescription for a short-acting opioid medication within 60 days of the date of the pharmacy filling the current prescription as evidenced by the member's prescription profile.
The initial prescription 5-day supply limitation for short-acting opioid medications does not apply to prescriptions for the following conditions and care instances*:
- Active oncology diagnosis;
- Hospice care;
- End-of-life care (other than hospice);
- Palliative care;
- Skilled nursing facility care;
- Traumatic injury, excluding post-surgical procedures; and
- Post-surgical procedures. Initial prescriptions for short acting opioid medications for post-surgical procedures are limited to a supply of no more than 14 days.
*Conditions and care-instances must be communicated to the pharmacy by documenting on the hard copy prescription or communicating it telephonically, electronically or via fax to the pharmacy. Please refer to Exhibit 310-V-2 - 5-Day Supply Limit of Prescription Opioid Medications Exclusion Specifications under Chapter 300 of the
AHCCCS Medical Policy Manual
, Section, 310, Covered Services, Exhibit 310-V - Prescription Medication-Pharmacy Services for more detailed information.
Please refer to Exhibit 310-V-3 - ICD-10 CM Diagnosis code Description under Chapter 300 of the
AHCCCS Medical Policy Manual
, Section 310, Covered Services, Exhibit 310-V - Prescription Medication-Pharmacy Services for a list of applicable ICD-10 codes for traumatic injury.
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