Opioid Therapeutic Duplication Edits
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This document explains Alaska Medicaid's implementation of automated therapeutic duplication edits for opioid analgesics, describing which products/categories trigger denials, the 19-day look-back window, override/prior authorization options, and point-of-sale override codes. It affects Alaska Medicaid recipients, prescribers, and pharmacies.
No material clinical or coverage changes in this revision.
Therapeutic Duplication Coverage Rules
Therapeutic duplication coverage criteria and exceptions
Alaska Medicaid will deny claims that represent therapeutic duplication of opioids according to category and listed equivalencies; exceptions and overrides are available.
Same-category duplication
- Multiple claims for similar products within the same category during the 19-day look-back will be denied (example: Morphine JR and Oxycodone JR would trigger the edit).
- Products from different categories will not trigger the edit (example: Hydrocodone/APAP and Morphine ER would not trigger the edit).
Suboxone/Subutex special rule
- If a recipient has a claim for Suboxone or Subutex within the last 19 days, all opioid claims will reject regardless of category.
- To request an override for a Suboxone/Subutex-related rejection the prescriber must contact the Magellan Clinical Call Center at (800) 331-4475.
- If an override is obtained for Suboxone/Subutex, any existing prior authorization for Suboxone or Subutex will be ended.
Overrides for dosing or therapy changes
- If rejection is due to a dosing or therapy change and the prescription is written by the same prescriber or prescriber group, the pharmacy may request an override by contacting the Magellan Clinical Call Center at (800) 331-4475.
- If rejection is due to a dosing or therapy change and the prescription is from a different prescriber or prescriber group, the prescriber may request an override by contacting the Magellan Clinical Call Center at (800) 331-4475 or by faxing a prior authorization request form to (888) 603-7696.
Opioid Product Equivalencies and Look-back
| Codeine/APAP (combo) | mapped equivalent: Oxycodone/ASA |
| Codeine/ASA (combo) | mapped equivalent: Oxycodone/ASA |
| Hydrocodone/APAP (combo) | mapped equivalent: Propoxyphene/APAP |
| Hydrocodone/ASA (combo) | mapped equivalent: Pentazocine/Naloxone |
| Ibuprofen/Hydrocodone (combo) | mapped equivalent: Ibuprofen/Oxycodone |
| Oxycodone/APAP (combo) | mapped equivalent: Butorphanol Nasal Spray |
| Codeine 15 mg tab | mapped equivalent: Hydromorphone 1 mg/mL |
| Codeine 30 mg tab | mapped equivalent: Methadone 5 mg/5 mL |
| Codeine 60 mg tab | mapped equivalent: Methadone 10 mg/5 mL |
| Codeine 15 mg tab sol | mapped equivalent: Methadone 10 mg/mL |
Overrides, Prior Authorization, and Point-of-Sale Codes
Override and prior authorization process
If a claim is rejected because of a dosing or therapy change: - If the prescription is written by the same prescriber or prescriber group as the previous claim(s), the pharmacy may request an override by contacting the Magellan Clinical Call Center at (800) 331-4475. - If the prescription is from a different prescriber or prescriber group, the prescriber may request an override by contacting the Magellan Clinical Call Center at (800) 331-4475 or by faxing a prior authorization request form to the Magellan Clinical Call Center at 888-603-7696. If a recipient has a claim for Suboxone or Subutex within the last 19 days, all opioid claims will reject and the prescriber must contact the Magellan Clinical Call Center at (800) 331-4475 to request an override; if an override is obtained any existing prior authorization for Suboxone or Subutex will be ended.
- Pharmacy override option when same prescriber or prescriber group: Magellan Clinical Call Center (800-331-4475).
- Prescriber override option when different prescriber/prescriber group: Magellan Clinical Call Center (800-331-4475) or fax prior authorization form to 888-603-7696.
- Special rule for Suboxone/Subutex within 19 days: prescriber must contact Magellan Clinical Call Center; existing PA will be ended if override obtained.
Point-of-sale override codes (NCPDP fields)
Point-of-sale overrides may be submitted using specific NCPDP fields and values to bypass a therapeutic duplication rejection for certain settings: use Patient Residence (NCPDP field 384-4X) = '11' for hospice; Prior Authorization Type Code (NCPDP field 461-EU) = '2' for cancer treatment; Patient Residence (NCPDP field 384-4X) = '4' for long term care.
- Patient Residence (NCPDP field 384-4X) = '11' — hospice
- Prior Authorization Type Code (NCPDP field 461-EU) = '2' — cancer treatment
- Patient Residence (NCPDP field 384-4X) = '4' — long term care
Terminology and Category Groupings
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