CMS and the Evzio prescription

The U. S. Surgeon General launched its “ Turn the Tide RX” campaign several months ago in an effort to curb opioid abuse. The campaign focuses on changing the way opioids are prescribed by treating physicians and by providing expanded access to medication assisted therapy for those at risk of opioid overdose. The campaign also seeks to characterize opioid addiction as a chronic illness. The Center for Disease Controls similarly issued guidelines that recommend limits on opioids. Physicians are urged to “assess, tailor and taper” opioid therapy when an individual is over sedated. We are starting to see the implementation of these changes in treatment records.

Given this background, we recently submitted an MSA proposal to CMS that involved an individual who had been prescribed Fentanyl for several years. Although the claimant did not have any history of substance abuse or aberrant drug seeking behavior, her physician, decided to include a prescription for Evzio , a naloxone injection, to be used in the event of an overdose. Our submission did not include the Evzio since this emergency type of treatment was not warranted in this case. CMS’ initial determination included one annual refill of the Evzio for life resulting in the addition of over $105,000.00 to the MSA.

We prepared a request for reconsideration seeking the removal of the Evzio, since it was not medically necessary in this case. We also argued that as a matter of policy, the expansion of the MSA in anticipation of an opioid overdose only served to provide an opioid addict with more funds to be spent on opioids. It was essentially the ethical equivalent of handing out more poison while pretending an antidote was being served. We are pleased to report that CMS eventually removed the Evzio . It noted that the claimant’s higher level of opioid use, without any history of overdose, substance abuse disorder or concurrent benzodiazepine, did not make the long-term use of Evzio reasonably probable.

We recommend that parties seek clarification for the necessity of a naloxone or Evzio prescription when added to a treatment regimen by a prescriber. Absent a likelihood of overdose, it is unwarranted. The better approach by the treating physician would be the implementation of an opioid weaning program.

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