Doctors may prescribe opioids, a class of drugs used to treat pain, after surgery or an injury. Although opioids can be an important part of treatment, they have serious risks like addiction, abuse, and overdose, especially if used continuously. This is true even for seniors and other people with Medicare coverage.

That’s why Medicare is working with doctors and pharmacists to help you use opioids safely. Medicare is also using new drug management programs to look for potentially high-risk opioid use.

The new policies aren’t “one size fits all”—instead, they’re tailored for different types of Medicare prescription opioid users. These policies don’t apply to people in long-term care facilities, those in hospice, getting palliative or end-of-life care, or people being treated for active cancer-related pain.

Safety checks at the pharmacy

When a prescription is filled, Medicare drug plans perform additional safety checks and may send pharmacies an alert to monitor the safe use of opioids and certain other medications. 

Safety checks may cover situations like:

• Possible unsafe amounts of opioids. The pharmacist or Medicare drug plan may need to more closely review a prescription with the prescribing doctor if a patient has one or more opioid prescriptions that total more than a certain amount.

• First prescription fills for opioids. These may be limited to a 7-day supply or less for acute pain if a patient hasn’t recently taken opioids (like within the past 60 days). This safety check applies only to new users of prescription opioids.   

• Use of opioids with benzodiazepines (a class of drugs commonly used for anxiety and sleep), which can be dangerous when taken in combination.

If a prescription can’t be filled as written, the pharmacist will provide a notice explaining how the patient or doctor can contact the Medicare drug plan to ask for a coverage determination (the first coverage decision made by the Medicare drug plan). The patient or doctor also can ask the plan for an exception to its rules before the patient goes to the pharmacy, so they know whether or not the prescription will be covered.

Drug Management Programs

As of Jan. 1, 2019, some Medicare drug plans have a drug management program in place to help people with Medicare use these medications safely. If a patient gets opioids from multiple doctors or pharmacies, the Medicare drug plan might connect with the doctors to make sure the patient needs these medications and is using them safely and appropriately. 

More information about safety checks and drug management programs is available on Medicare.gov at Medicare drug plan coverage rules.

Greg Dill, Acting Consortium Administrator, CA, for the Centers for Medicare & Medicaid Services, CMS’ Kansas City Regional Office.