Product Lines:
Advantage MD, EHP, Priority Partners and USFHP.

Eligible Population:
Members 18 years and older as of January 1 of the measurement year. This includes HealthChoice Performance Measure reporting for Priority Partners.

Definition:
The percentage of members 18 years of age and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Note: A lower rate indicates better performance.

Continuous Enrollment:

• The measurement year.

Best Practice and Measure Tips

• The measure utilizes pharmacy claims data for opioid medications filled.
• Members are included in measure once a dispensing event for an opioid medication occurs during the Intake Period.
• All of the medications lists in the Opioid Medications table are used to identify opioid medication dispensing events.
• To identify same or different drugs, use the medication lists specified for the measure in the Opioid Medications table. Drugs in different medication lists are considered different drugs. For example, a dispensing event from the Acetaminophen Codeine Medications List is considered a different drug than a dispensing event from the Codeine Sulfate Medications List.
• Schedule follow-up visits to ensure members are not showing opioid use disorder.
• Safely discontinue the opioid therapy when dosage exceeds 120 morphine milligram equivalents daily.
• Utilize non-narcotic and non-pharmacologic measures to control pain as part of a comprehensive pain management plan.
• Provide educational materials and resources that include information on treatments and process and options.
• Stay inform about the latest opioid research and guidelines by visiting:
  • Centers for Disease Control and Prevention (CDC)
    • CDC offers a number of materials and tools about opioid prescribing guidelines.
    • Permission is not needed to print, copy, or distribute any materials. Visit the CDC website.
• U.S. Department of Health and Human Services
  • HHS (hhs.gov) offers a number of materials and tools about opioid prescribing guidelines:
    • Prevention
    • Treatment
    • Recovery
  • The Substance Abuse and Mental Health Services Administration (SAMHSA) guidance and resources for opioid-related treatment programs
• Maryland Opioid Operational Command Center
  • Provides free resources regarding prevention, treatment and recovery. Visit the website.
• The following opioid medications are excluded from this measure:
  • Injectables.
  • Opioid-containing cough and cold products.
  • Single-agent and combination buprenorphine products used as part of medication-assisted treatment of opioid use disorder (buprenorphine sublingual tablets, buprenorphine subcutaneous implant and all buprenorphine/naloxone combination products).
  • Methadone for the treatment of opioid use disorder
  • Ionsys® (fentanyl transdermal patch).

Ways to help our member:

• Refer the member to a care manager:
  • The Johns Hopkins Health Plans Care Management team offers a variety of services to help members who are living with substance abuse and mental health may receive confidential care management support and coordination of care from a Licensed Clinical Social Worker. These behavioral health clinicians help members navigate their treatment needs for conditions such as depression, anxiety disorders, addictions, and autism spectrum disorders. For Priority Partners members, we work with Carelon Behavioral Health to manage mental health needs.
  • Please send us your referrals by contacting us at:
    • Phone: 800-557-6916
    • Monday through Friday: 8 a.m. to 5 p.m.
    • Voicemail messages received after normal business hours will be addressed the following business day.
    • EHP Behavioral Health: 410-424-4891
    • EHP Behavioral Health (Secured): 410-424-4765
    • USFHP Behavioral Health: 410-424-4839
    • AMD Behavioral Health, Inpatient & Outpatient: 844-340-2217
    • Email: [email protected]
    • View Care Management Services
• When prescribing opioids:
  • Use the lowest dosage of opioids for the shortest length of time possible.
  • Refer to the CDC guidelines for prescribing Opioids for Pain
  • Establish and measure goals for pain and function.
  • Discuss benefits and risks of opioid and non-opioid treatments.
  • Engage family/significant others in the treatment plan. Advise them about the importance of treatment and attending appointments.
  • Schedule follow up appointments to reassess and adjust any medication regimens.
  • Provided a printed copy of treatment plan and ensure member adhere to the treatment plan.
  • Communications between the behavioral health provider and the Primary Care Physician (PCP) is encourage and care should be coordinated.

Measure Exclusions

Required Exclusion:

• Members in hospice or using hospice services anytime during the measurement year.
• Members who died any time during the measurement year.
• Palliative Care
• Cancer any time during the measurement year.
• Sickle Cell Disease any time during the measurement year.

Exclusion Codes

• Cancer
  • Malignant Neoplasms ICD-10-CM: C00.0-C00.6, C00.8, C00.9, C01, C02.0-C02.4, C02.8, C02.9, C03.0, C03.1, C03.9, C04.0, C04.1, C04.8, C04.9, C05.0, C05.1, C05.2, C05.8, C05.9, C06.0, C06.1, C06.2, C06.80, C06.89, C06.9, C07, C08.0, C08.1, C08.9, C09.0, C09.1, C09.8, C09.9, C10.0, C10.1-C10.4, C10.8, C10.9, C11.0-C11.3, C11.8, C11.9, C12, C13.0, C13.1, C13.2, C13.8, C13.9, C14.0, C14.2, C14.8, C15.3, C15.4, C15.5, C15.8, C15.9, C16.0- C16.6, C16.8, C16.9, C17.0- C17.3, C17.8, C17.9, C18.0- C18.9, C19, C20, C21.0; C92.60, C93.92, C93.Z0, C93.Z1, C93.Z2, C94.00, C94.01, C94.02, C94.20, C94.21, C94.22, C94.30, C94.31, C94.32, C94.40, C94.41, C94.42, C94.6, C94.80, C94.81, C94.82, C95.00, C95.01, C95.02, C95.10, C95.11, C95.12, C95.90, C95.91, C95.92, C96.0, C96.2, C96.20, C96.21, C96.22, C96.29, C96.4, C96.5, C96.6, C96.9, C96.A, C96.Z;
    • Additional codes apply.
• Sickle Cell Diseases
  o ICD-10-CM: D57.00, D57.01, D57.02, D57.03, D57.04, D57.09, D57.1, D57.20, D57.211, D57.212, D57.213, D57.214, D57.218, D57.219, D57.40, D57.411, D57.412, D57.413, D57.414, D57.418, D57.419, D57.42, D57.431, D57.432, D57.433, D57.434, D57.438, D57.439, D57.44, D57.451, D57.452, D57.453, D57.454, D57.458, D57.459, D57.80, D57.811, D57.812, D57.813, D57.814, D57.818, D57.819D57.00- D57.03, D57.09, D57.1, D57.20, D57.211- D57.213, D57.218, D57.219, D57.40, D57.411- D57.413, D57.418, D57.419, D57.42, D57.431- D57.433, D57.438, D57.439, D57.44, D57.451-D57.453, D57.458, D57.459, D57.80, D57.811- D57.813, D57.818, D57.819

Measure Medications

To identify “same” or “different” drugs, use Table HDO-A, which identifies the medications lists for the measure. Dispensing events from any of the Fentanyl medication lists, even if they are on different rows, are all considered the “same” drug.

For all other types of opioids, the table includes a “Medication Lists” column that identifies the “same” high-risk medications by grouping them on the same row. For example, a dispensing event from the Codeine Sulfate 15 mg Medications List is considered the same drug as a dispensing event from the Codeine Sulfate 30 mg Medications List. Conversely, a dispensing event from the Codeine Sulfate 15 mg Medications List is considered a different drug than a dispensing event from the Acetaminophen Codeine 15 mg Medications List because they are in different table rows.

Table HDO-A: Opioid Medications