Effective December 2, 2019, the Alabama Medicaid Agency will implement hard edits on cumulative daily MME claims exceeding 200 MME/day. A phase-in period for claims exceeding 150 MME/day, but less than 200 MME/day, will also be implemented.
Higher doses of opioids are associated with higher risk of overdose and death - even relatively low dosages (20-50 MME per day) may increase risk.1 Therefore, Alabama Medicaid will limit the amount of cumulative MME allowed per day on opioid claims. The edit began at 250 cumulative MME per day and is gradually being decreased over time. The final cumulative MME target is scheduled to be 90 MME per day.
Hard Edit Implementation (Greater than 200 MME):
Effective December 2, 2019, opioid claims that exceed a cumulative MME of 200 MME/day will be denied.
The universal PA 0009996322 will no longer be valid to bypass the 200 MME edit.
Pharmacy override requests for quantities exceeding the MME limit may be submitted to Health Information Designs (HID) and will be reviewed for medical necessity. See the link below for an override form.
Phase-In Period (150 MME – 200 MME):
Effective December 2, 2019, claims that exceed the cumulative daily MME limit of 150 MME/day will be denied. The dispensing pharmacist will be provided a universal prior authorization (PA) number on the rejection screen and may enter this universal PA number on the claim to allow it to be paid.
Pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.