§3174-UU. Reimbursement for opioid drugs for the treatment of pain

This section applies to reimbursement under the MaineCare program for opioid drugs for the treatment of pain.   [PL 2011, c. 657, Pt. O, §2 (NEW).]

1.  Treatment of a new onset of acute pain.  The department shall establish limits for MaineCare reimbursement of opioid drugs that are prescribed as medically necessary in response to a new onset of acute pain. After the initial 15-day prescription, the limits established may not exceed 42 days per year without prior authorization. In order to qualify for reimbursement under this subsection, the prior authorized prescription may not provide for more than 14 days of medication and requires a face-to-face visit between the prescriber and the MaineCare member. Notwithstanding the provisions of this subsection, the department shall limit to a period of 60 days following the surgical procedure MaineCare reimbursement for opioid drugs as treatment of post-operative care prescribed following a surgical procedure for which the medical standard of care includes the use of opioids. A MaineCare member who suffers from intractable pain and for whom opioid drugs are medically necessary beyond the limits set by this subsection may qualify for opioid drugs under subsection 2 as treatment for long-term chronic pain.

[PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]

2.  Treatment of long-term chronic pain.  Reimbursement for opioid drugs beyond the limit set in subsection 1 is allowed by prior authorization if the MaineCare member participates in one or more therapeutic treatment options established by the department through rulemaking.

In order to qualify for reimbursement for opioid drugs under this subsection, the MaineCare member must:

A. Have failed to have an adequate response to the prescribed therapeutic treatment options;   [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]

B. Have completed the prescribed therapeutic treatment options in accordance with the guidelines and show signs of regression; or   [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]

C. Have completed at least 50% of the prescribed therapeutic treatment options under this subsection, after which the prescriber recommends that adequate control of pain will not be obtained under the therapeutic treatment options.   [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]

The department shall limit reimbursement for opioids for a MaineCare member who fails to have an adequate response to the prescribed therapeutic treatment options, subject to exception based on medical necessity. The department may include in rulemaking the establishment of a daily dosing limit, subject to exception.

The department may waive the requirement of therapeutic treatment options through prior authorization when participation is not feasible and opioid treatment is medically necessary.

The department may allow a MaineCare member who is participating in a course of treatment recommended by a prescriber, including alternatives, in accordance with rules adopted by the department to obtain a prior authorization for physical therapy in excess of 2 visits to a maximum of 6 visits.

[PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]

3.  Second opinion.  In order for a prescription to qualify for reimbursement under this section, prior to prescribing an opioid drug for a medical diagnosis known typically to have a poor response to opioid drugs, a prescriber shall obtain an evaluation from a prescriber from outside the practice of the prescriber.

[PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]

4.  Current use.  The department may delay until January 1, 2013 the application of this section to the reimbursement for opioid drugs for MaineCare members who have been receiving such treatment consistently for 6 months or longer on the effective date of this section. The department may require the development of a protocol for proper, safe and effective tapering from opioid use when appropriate and may adopt exceptions to the requirements of this section based on diagnosis or condition or on the basis of daily doses.

[PL 2011, c. 657, Pt. O, §2 (NEW).]

5.  Collaboration.  The department shall seek input from pain specialists, addiction medicine specialists and members of the department's physician advisory committee in the development of rules governing this section.

[PL 2011, c. 657, Pt. O, §2 (NEW).]

6.  Morphine equivalent dose.  The department may establish and utilize a total daily morphine equivalent dose calculation when developing rules to implement this section.

[PL 2011, c. 657, Pt. O, §2 (NEW).]

7.  Exceptions.  This section does not apply to reimbursement for opioid drugs for the following MaineCare members as specified in rules adopted by the department or as established through the MaineCare preferred drug list:

A. A MaineCare member who is receiving opioid drugs for symptoms related to HIV, AIDS, cancer and certain other qualifying diseases and conditions, as established by department rule;   [PL 2011, c. 657, Pt. O, §2 (NEW).]

B. A MaineCare member who is receiving opioid drugs during inpatient treatment in a hospital or during hospice care;   [PL 2011, c. 657, Pt. O, §2 (NEW).]

C. A MaineCare member who is receiving opioid drugs at certain qualifying low doses, as established by department rule;   [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]

D. A MaineCare member for whom MaineCare reimbursement for opioid drugs for the treatment of addiction is restricted by limits applicable to methadone and buprenorphine and naloxone combination drugs; and   [PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]

E. A MaineCare member who is residing in a nursing facility.   [PL 2013, c. 368, Pt. AAAAA, §1 (NEW).]

[PL 2013, c. 368, Pt. AAAAA, §1 (AMD).]

8.  Rules.  The department shall adopt rules to implement this section. Rules adopted under this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.

[PL 2011, c. 657, Pt. O, §2 (NEW).]

§3174-UU. Methadone reimbursement limitations (As enacted by PL 2011, c. 657, Pt. S, §1 is REALLOCATED TO TITLE 22, SECTION 3174-VV)

SECTION HISTORY

RR 2011, c. 2, §27 (RAL). PL 2011, c. 657, Pt. O, §2 (NEW). PL 2011, c. 657, Pt. S, §1 (NEW). PL 2013, c. 368, Pt. AAAAA, §1 (AMD).