The Drug Management Program
Memorial Hermann Health Plan is committed to improving the health and wellness of our members and community. We are working together with your doctor, pharmacists and other healthcare professionals and partnering with our members in addressing the risks, dangers, and use of prescription pain medications.
Prescription pain medications including opioids can help manage pain when used appropriately such as pain due to surgery or an injury, but they also can be dangerous when misused or used inappropriately leading to serious risks of addiction, overdose or death. These risks can be increased when you get pain medications from multiple doctors or pharmacies and if you take other medications that can interact with your opioids such as Benzodiazepine – a class of medication that can be used to treat conditions like anxiety or seizures. Examples of a Benzodiazepine drugs include Alprazolam (Xanax®), Diazepam (Valium®), and Clonazepam (Klonopin®). Examples of opioid pain medications include Oxycodone (OxyContin®), Hydrocodone (Vicodin®), and Hydromorphone (Dilaudid®) to name a few.
Safety is our Priority
The goal of the DMP is to improve care coordination for safer use of benzodiazepines and opioid medications. All Medicare drug plans have a drug management program (DMP) to help patients who are at risk for prescription drug abuse. If you get opioids from multiple doctors or pharmacies, or if you had a recent opioid overdose, we may talk with your doctors to make sure you need these medications and that you are using them safely.
Memorial Hermann Health Plan works with your pharmacists and doctors to do a safety review when you fill your prescriptions and to make sure you need these medications. If we identify that your prescription opioids and benzodiazepines are not safe or may pose a risk or danger to your health, then we may limit your coverage of these drugs under our drug management program and may require you to get these medications only from certain doctors or pharmacies to better coordinate your health care needs. Memorial Hermann Health Plan will notify you by letter if you will be affected by the drug management program. You and your doctor can also disagree and appeal any decision by the plan.
If we decide your use of prescription opioid or benzodiazepine medications is not safe, we may limit how you can get those medications. If we place you in our DMP program, the limitations may be:
- Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain pharmacy(ies)
- Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain doctor(s)
- Limiting the amount of opioid or benzodiazepine medications we will cover for you
If we plan on limiting how you may get these medications or how much you can get, we will send you a letter in advance. The letter will explain the limitations we think should apply to you. You will have an opportunity to tell us which doctors or pharmacies you prefer to use, and about any other information you think is important for us to know. After you’ve had the opportunity to respond, if we decide to limit your coverage for these medications, we will send you another letter confirming the limitation. If you think we made a mistake or if you disagree with our determination or with the limitation, you and your prescriber have the right to appeal. If you appeal, we will review your case and give you a decision. If we continue to deny any part of your request related to the limitations that apply to your access to medications, we will automatically send your case to an independent reviewer outside of our plan. See Chapter 9 in your Evidence of Coverage for information about how to ask for an appeal.
Exceptions to the DMP
The safety reviews and Drug Management Programs (DMP) generally won’t apply to you if you have active cancer related pain, sickle cell disease, are in hospice care, have palliative care, or end-of-life care, or if you live in a long-term care facility. If you believe that you have any of the conditions listed, please call our Customer Service Department and inform the plan.
Talk to your Doctor
Talk with your doctor about all your pain treatment options, including whether taking an opioid medication is right for you. You might be able to take other medications or do other things to help manage your pain with less risk. What works best is different for each patient. Treatment decisions to start, stop or reduce prescription opioids should be made by you and your doctor. For more information on safe and effective pain management, visit CDC website.
Related Resources
You may also learn more about opioid medications, patient safety, requirements of the DMP, and resources to assist you with taking opioid pain medications and benzodiazepine safety by visiting the following websites or resources.
Additional Questions or Concerns
Do you have questions, concerns, need more information or documents? Call our CapitalRX Customer Service department at (888) 227-7940 (TTY 711) to learn more about how our Drug Management Program (DMP) program works. Hours of operation are 24 hours a day/7 days a week/365 days a year.