A Prescriber’s Guide to the New Medicare Part D Opioid Overutilization Policies for 2019

December 12, 2018

Effective January 1, 2019, CMS will have new opioid overutilization policies go to into effect. Below is an excerpt from a guidance document on the new policies.


The Centers for Medicare & Medicaid Services (CMS) understands the magnitude of our nation’s opioid epidemic and its impact on communities. Opioid medications are effective at
treating certain types of pain, but have serious risks such as increasing tolerance, addiction, overdose, and death. Given the scope of the crisis, CMS published a roadmap in June 2018, outlining our efforts to address this issue. The roadmap details our three-pronged approach to combating the opioid epidemic going forward: 

  1. prevention of new cases of opioid use disorder (OUD)
  2. treatment of patients who have already become dependent on or addicted to opioids
  3. utilization of data from across the country to better target prevention andtreatment activities.

Through our 2019 Medicare Part D opioid overutilization initiatives, CMS seeks to strengthen and broaden our partnership with providers to address the opioid crisis.

What Providers Need to Know:

CMS finalized new policies for Medicare drug plans to follow starting on January 1, 2019. These policies involve further partnership with providers and prescription drug plans. Providers are in the best position to identify and manage potential opioid overutilization in the Medicare Part D population. Medicare prescription drug plans can assist providers by alerting them about unusual utilization patterns in prescription claims. The new policies include improved safety alerts when opioid prescriptions are dispensed at the
pharmacy, and drug management programs to better coordinate care when chronic high-risk opioid use is present.

Read the full CMS document