HCA to implement opioid clinical policy for Apple Health (Medicaid) on Nov. 1

New policy meant to help prevent opioid misuse and addiction 

OLYMPIA–Each additional day of prescription opioid use increases the risk of opioid use disorder (misuse and addiction). Approximately 700 Washingtonians die each year because of opioid overdose.

To help curb this public health crisis, the Health Care Authority (HCA) beginning on Nov. 1, 2017, will limit the quantity of opioids that providers can prescribe to Apple Health clients for short-term use. The policy is a tool to prevent misuse and addiction, an opportunity to promote safe prescribing practices, and a direct response to Governor Inslee’s executive order to combat the opioid crisis.

The policy sets the following limits:

  • For people ages 20 or younger: 18 tablets or capsules (about a three-day supply)
  • For people ages 21 or older: 42 tablets or capsules (about a seven-day supply)

“This is a public health crisis, affecting communities and families around Washington and the nation,” said HCA Chief Medical Officer Dr. Dan Lessler.

“Risk of long-term opioid use goes up with every day’s supply on the initial prescription, and with every refill. By prescribing the lowest effective dose for the shortest time needed, providers can help prevent opioid use disorder and help keep unused medication out of our communities.”

Prescribers are able to override the limits if they feel it is medically necessary. In addition, the policy exempts:

  • Patients who are undergoing active cancer treatment or who are in hospice, palliative care, or end-of-life care.
  • Patients who are already on chronic (ongoing) opioid therapy.

The policy aligns with U.S Centers for Disease Control and Prevention guidelines.

“Physicians see the tragic effects of the opioid epidemic every day,” said Washington State Medical Association president and Seattle pediatrician Donna Smith, MD. “We are grateful that the state is joining with physicians and providers to look at evidence-based approaches to the crisis. These new guidelines will encourage all of us to stop and consider options for acute pain management, discuss the risks of these powerful medications, and still allow us to respond to each patient’s unique situation.”

“Opioids are crucial to helping patients manage pain and recover, but they also carry a serious risk of addiction that must be managed very carefully,” said Washington State Hospital Association president and CEO Cassie Sauer. “This is a huge problem in our state and we’re glad to be working with HCA, WSMA and others to establish clear guidelines and share the information that will help providers manage patient pain in a responsible way.

Other states already have implemented such policies, and major pharmacy benefits managers Express Scripts and CVS Caremark have announced opioid dispensing limits.

HCA also plans to implement an opioid clinical policy for the Uniform Medical Plan, which is the self-insured plan for Public Employees Benefits Board (PEBB) Program members. That policy change will take effect in early 2018.

Learn more about the new policy and Washington’s opioid crisis