Coverage for Abuse Deterrent Drug Products; Issued 12/19/2017

[LOGO] CHARLES D. BAKER GOVERNOR KARYN E. POLITO LIEUTENANT GOVERNOR COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation DIVISION OF INSURANCE 1000 Washington Street, Suite 810 • Boston, MA 02118-6200 (617) 521-7794 • Toll-free (877) 563-4467 http://www.mass.gov/doi JAY ASH SECRETARY OF HOUSING AND ECONOMIC DEVELOPMENT JOHN C. CHAPMAN UNDERSECRETARY OF CONSUMER AFFAIRS AND BUSINESS REGULATION GARY D. ANDERSON COMMISSIONER OF INSURANCE ## BULLETIN 2017-08 To: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations From: Gary Anderson, Commissioner of Insurance Date: December 19, 2017 Re: Coverage for Abuse Deterrent Opioid Drug Products The Division of Insurance (“Division”) issues this Bulletin to provide information to Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations (“Carriers”) offering insured health coverage in the Commonwealth of Massachusetts. Chapter 258 of the Acts of 2014 (“Chapter 258”) requires that, if health insurance is considered “creditable coverage under section 1 of chapter 118M,” then the health insurance: shall provide coverage for abuse deterrent opioid drug products listed on the formulary, compiled pursuant to subsection (b) of section 13 of chapter 17, on a basis not less favorable than non-abuse deterrent opioid drug products that are covered by such policy, contract, agreement, plan or certificate of insurance. An increase in patient cost sharing shall not be allowed to achieve compliance with this section. The Division expects all Carriers to provide coverage for any abuse deterrent opioid drug product that is listed on the formulary, and such coverage must be on a basis not less favorable than for comparable non-abuse deterrent opioid drug products that the health insurance policy covers. As an example, for those health plans with differing copayment levels based on the benefit tier of which a drug product is assigned, a Carrier is to charge the same cost-sharing for an abuse deterrent drug product as the non-abuse deterrent drug product that the Drug Formulary Commission (“DFC”) identifies as chemically equivalent to an abuse deterrent product. For those abuse deterrent drug products where DFC has not identified a non-abuse deterrent equivalent, Carriers are not restricted as to the benefit tier to which the abuse deterrent drug product is assigned. Bulletin 2017-08 December 19, 2017 Page 2 of 4 Carriers are permitted to employ medical management and utilization review processes as permitted under federal and state law, but are required to employ systems that do not treat abuse deterrent drug products in a manner less favorable than used for non-abuse deterrent drug products. Thus, if a Carrier approves coverage for a non-abuse deterrent drug product, then the Carrier must approve coverage for the abuse-deterrent drug product that DFC has identified as chemically equivalent. This would apply to all utilization processes and may include, but not be limited to: prior authorization, concurrent review, and step therapies. For those abuse deterrent drug products that have no comparable non-abuse deterrent equivalent, Carriers may utilize appropriate medical management and utilization review processes, but Carriers may not deny coverage for any abuse deterrent drug that is on the formulary. The Division expects that Carriers will take all necessary steps to ensure that their internal processes and systems are modified to meet the requirements for the abuse deterrent opioid drug products listed on the attachment to this Bulletin. The Division will provide sufficient notice to Carriers of any new abuse deterrent drug products included on the formulary that will require Carriers to take steps to ensure that their internal processes and systems are modified to meet the coverage requirements for abuse deterrent opioid drug products within an appropriate time period as communicated by the Division. Additional information on the Drug Formulary may be found on mass.gov at the Drug Formulary Commission website. If you have any questions about this Bulletin, please contact Tracey McMillan, Director of Bureau Managed Care at 617-521-7347 or Tracey.T.McMillan@massmail.state.us. Bulletin 2017-08 December 19, 2017 Page 3 of 4 # ATTACHMENT A: Formulary of Chemically Equivalent Substitutions for Opioids with a Heightened Public Health Risk | HPHR Opioid (Non-Abuse Deterrent Drug Products) | Interchangeable Abuse Deterrent Drug Product | Commercially Available Strengths | Dosing Frequency | ADP Efficacy Category | | --- | --- | --- | --- | --- | | Kadian^{®} (morphine ER capsules) | Embeda^{®} (morphine sulfate ER/naltrexone capsule) | 20 mg/0.8 mg 30 mg/1.2 mg 50 mg/2 mg 60 mg/2.4 mg 80 mg/3.2 mg | Every 24 hours or every 12 hours | Category II | | Morphine ER 12 or 24 hour capsules (generic Kadian^{®}) | | | | | | Morphine ER 24 hour capsules (generic Avinza^{®}) | | | | | | Morphine ER tablet (generic MS Contin^{®}) | | | | | | MS Contin^{®} (morphine ER tablet) | | | | | | Zohydro ER^{®} (hydrocodone ER capsule) | Hysingla ER^{®} (hydrocodone ER tablet) | 20 mg 30 mg 40 mg 60 mg 80 mg 100 mg 120 mg | Every 24 hours | Category II | | Kadian^{®} (morphine ER capsules) | Morphabond ER^{®} (morphine sulfate ER tablet) | 15 mg 30 mg 60 mg 100 mg | Every 12 hours | Category II | | Morphine ER 12 or 24 hour capsules (generic Kadian^{®}) | | | | | | Morphine ER 24 hour capsules (generic Avinza^{®}) | | | | | | Morphine ER tablet (generic MS Contin^{®}) | | | | | | MS Contin^{®} (morphine ER tablet) | | | | | | Kadian^{®} (morphine ER capsules) | Arymo ER^{®} (morphine sulfate ER tablet) | 15 mg 30 mg 60 mg | Every 8 hours or every 12 hours | Category II | | Morphine ER 12 or 24 hour capsules (generic Kadian^{®}) | | | | | | Morphine ER 24 hour capsules (generic Avinza^{®}) | | | | | | Morphine ER tablet (generic MS Contin^{®}) | | | | | | MS Contin^{®} (morphine ER tablet) | | | | | Bulletin 2017-08 December 19, 2017 Page 4 of 4 # ATTACHMENT A: Formulary of Chemically Equivalent Substitutions for Opioids with a Heightened Public Health Risk CONTINUED | HPHR Opioid (Non-Abuse Deterrent Drug Products) | Interchangeable Abuse Deterrent Drug Product | Commercially Available Strengths | Dosing Frequency | ADP Efficacy Category | | --- | --- | --- | --- | --- | | No equivalent HPHR opioid identified | Nucynta ER® (tapentadol ER tablet) | 50 mg 100 mg 150 mg 200 mg 250 mg | Every 12 hours | Category II | | No equivalent HPHR opioid identified | Oxaydo® (oxycodone IR tablet) | 5 mg 7.5 mg | Every 4-6 hours | Category III | | No equivalent HPHR opioid identified | Oxycodone ER tablet | 10 mg 15 mg 20 mg 30 mg 40 mg 60 mg 80 mg | Every 12 hours or every 8 hours | Category II | | No equivalent HPHR opioid identified | OxyContin® (oxycodone ER tablet) | 10 mg 15 mg 20 mg 30 mg 40 mg 60 mg 80 mg | Every 12 hours or every 8 hours | Category II | | No equivalent HPHR opioid identified | Xtampza ER® (oxycodone ER capsule) | 9 mg 13.5 mg 18 mg 27 mg 36 mg | Every 12 hours with food | Category II | | No equivalent HPHR opioid identified | Troxyca ER® (oxycodone ER/ naltrexone capsule) | 10/1.2 mg 20/2.4 mg 30/3.6 mg 40/4.8 mg 60/7.2 mg 80/9.6 mg | Every 12 hours | Category II | As approved by the Department of Public Health's Public Health Council on August 9, 2017