Effective 01/18/2018, Cigna-HealthSpring will have concurrent drug utilization review edits in place to manage the overutilization of opioid drugs at point-of-sale (POS).

Currently, the Morphine Equivalent Dose -MEDLIMIT edit enables the plan to review claims proactively at POS for opioid dosages and reject claims if they exceed the threshold of maximum opioid dosage.

Beginning on 01/01/2018, enhancements will be made to include PRESCRIBER thresholds in the MEDLIMIT edit. This will allow a claim to reject at POS if the MED and prescriber limits have been exceeded.

The new 2018 thresholds are: MED > 300mg AND ≥ 2 PRESCRIBERS

Any claim exceeding both of these thresholds will result in a reject at POS. The rejection is considered a soft rejection and will return the following message:

“MED XXXXX exceeded; Total MED YYYYMG”

*Please see attached for more information.