Effective this Sunday, Aug. 27, prior approval will be required for opioid analgesic doses for N.C. Medicaid and N.C. Health Choice (NCHC) beneficiaries which:

The prescribing provider may submit prior authorization requests to NCTracks through the NCTracks portal or by fax. New opioid analgesic prior authorization forms and revised clinical coverage criteria will be available on the NCTracks website.
Beneficiaries with diagnosis of pain secondary to cancer will continue to be exempt from prior authorization requirements.
This change also includes a new feature for prescribers to view only lock-in drugs or opioid analgesics when performing medication history searches for beneficiaries. However, the data represents only opioid claims paid by NC Medicaid and should not be used as a replacement for reviewing the NC Controlled Substance Reporting System (CSRS) as required by clinical coverage criteria and the recently passed Strengthen Opioid Misuse Prevention (STOP) Act, S.L. 2017-74.
It is important to note that the STOP Act further reduces the quantity for opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain effective January 1, 2018. To comply with this legislative mandate, NC Medicaid will be proposing that our 14-day limit to be further reduced to 5 and 7 days accordingly.
It is also important to note that pharmacy providers may dispense a 72-hour emergency supply for drugs requiring prior authorization. Federal law requires that this emergency supply be available to Medicaid beneficiaries for drugs requiring prior authorization (Social Security Act, Section 1927, 42 U.S.C. 1396r-8(d)(5)(B)). Use of this emergency supply will ensure access to medically necessary medications. The system will bypass the prior authorization requirement if an emergency supply is indicated. Pharmacies will use a “3” in the Level of Service field (418-DI) to indicate that the transaction is an emergency fill.
Some background on this policy and NC’s Opioid Action Plan
On June 27, 2017 at the NC Opioid Misuse and Overdose Prevention Summit, NC Governor Roy Cooper and NC Department of Health and Human Services Secretary Mandy Cohen announced North Carolina’s Opioid Action Plan, which outlines the key actions to reduce opioid addiction and overdose death. The goal is to change the trajectory of opioid deaths and reduce opioid overdose deaths by 20 percent by 2021.
NC’s Opioid Action Plan was developed with community partners to combat the opioid crisis. It is a living document that will be updated as we make progress on the epidemic and are faced with new issues and solutions. Strategies in the plan include:

  • Coordinating the state’s infrastructure to tackle the opioid crisis.
  • Reducing the oversupply of prescription opioids.
  • Reducing the diversion of prescription drugs and the flow of illicit drugs.
  • Increasing community awareness and prevention.
  • Making naloxone widely available.
  • Expanding treatment and recovery systems of care.
  • Measuring the effectiveness of these strategies based on results.

Over the past several months, the NC Division of Medical Assistance (DMA) Pharmacy Program has worked collaboratively with our Pharmacy and Therapeutics Committee and Physicians Advisory Group to update clinical coverage criteria for the use of opioids for pain management based on the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain and to align clinical coverage criteria with the strategies of reducing the oversupply of prescription opioids available for diversion  and misuse.
These updates began on May 1, 2017, when the refill threshold for all opioids and benzodiazepines prescriptions was increased from 75 percent to 85 percent.
DMA also reports that as providers are becoming more aware of the opioid crisis, utilization data already reflects a reduction in the use of opioids and an increase in non-opioid and non-drug pain management.
Other related useful resources: