Effective January 1, 2017, CMS will require Medicare plan sponsors to limit the daily cumulative dose of opioid products a member may obtain at Point of Sale (POS). The daily limit is referred to as the Morphine Equivalent Dose (MED) limit. The cumulative limit is based on a combination of drug strength and a product’s Morphine Milligram Equivalency (MME). The cumulative total daily MED value will be calculated based on the number of opioid drugs prescribed over a period of time which includes incoming claims and active claims history. Depending on the plan, there may be multiple MED limits with varying response levels (Soft or Hard reject).

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As previously communicated by Envolve Pharmacy Solutions and CVS Caremark®, Ambetter from MHS began using the CVS Caremark pharmacy network on May 2, 2016, while claims processing and payment remained with Envolve Pharmacy Solutions. This notice is to inform you that effective January 1, 2017, CVS Caremark will begin to process claims for Ambetter from MHS. All claims for Ambetter from MHS will now be reimbursed according to your CVS Caremark Network Enrollment Forms and be paid according to CVS Caremark processing rules and payment cycles, which will appear on your CVS Caremark 835 or remittance advice.

*Please see attached PDF for more information.