Pharmacy Services and Durable Medical Equipment

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Opioid Safety Initiative (OSI) General/Routine Prescriptions Urgent/Emergent Medicine What to Include in All Prescriptions Durable Medical Equipment (DME)

CCN covers routine medically necessary medication that’s part of an authorized episode of care and follows the rules of the VA National Formulary. CCN also covers medication that’s needed on an urgent and/or emergent basis.

  • Urgent or emergent medication must be on the Urgent/Emergent Formulary.
  • For medication that’s not on VA’s National Formulary, the provider needs to contact the Veteran’s authorizing VAMC, request a Formulary Request Review Form, fill out the form, and submit it back to the VAMC for approval or denial.

For all medications, including urgent and emergent, TriWest uses the Express Scripts (ESI) pharmacy network.

Urgent and emergent medications do NOT require an approved referral/authorization. However, for medication prescribed during an urgent care or retail walk-in clinic visit, clinic staff must FIRST call TriWest at 833-4VETNOW (833-483-8669) to confirm Veteran eligibility in order for the medication to be approved for fulfillment by the pharmacy.

Real-time urgent/emergent pharmacy dispensing information is available on Availity in the TriWest Payer Space. As per U.S. Drug Enforcement Administration (DEA) policies, some controlled substances will require the Veteran bring a hard copy of the prescription to the overseeing VA medical facility or CCN pharmacy.

Opioid Safety Initiative (OSI)
Department of Veterans Affairs Office of Integrated Veteran Care (IVC)

Objective

The intent of the VA Office of Integrated Veteran Care is to educate and ensure a greater awareness and adherence to safe opioid prescribing practices consistent with evidence-based guidelines as part of the Opioid Safety Initiative (OSI) requirements set forth by the Mission Act of 2018 (section 131) to include non-VA purchased care providers. Our objective is to build a collaborative effort between the VA and non-VA purchased care providers promoting improved patient outcomes and decreased incidence of serious and potentially catastrophic adverse effects related to opioid prescribing.

The Opioid Safety Initiative (OSI)

The Opioid Safety Initiative (OSI) was deployed in 2013 with the aim of ensuring the use of opioids in a safe, effective, and judicious manner. VA employed four strategies to address the crisis: education, pain management, risk mitigation, and addiction treatment. The OSI uses population health tools in the form of metrics available in pharmacy/medical claims data and electronic health records to identify patients who may be high-risk for adverse outcomes related to use of opioids and providers whose prescribing practices may not reflect the best evidence. Early outcome data showed a substantial reduction in high-dose opioid prescribing and concurrent benzodiazepine-opioid prescribing from pre-OSI data compared to post-OSI implementation.

Clinical Practice Guidelines

The 2022 VA/DoD Clinical Practice Guideline (CPG) for the Use of Opioids in the Management of Chronic Pain reflect the broader cultural transformation in the way pain is viewed and treated. The opioid crisis necessitates a cautious approach to opioid prescribing while embracing multimodal care and whole health principles for long-term success and management of chronic pain. These guidelines align well with the 2022 CDC CPG for Prescribing Opioids for Pain and the best interest of providers engaging in Veteran care.

Summary of Evidence-based Recommendations (Please see full CPG at link below for the full 20 recommendations):

  • Recommend against initiation of opioid therapy for the management of chronic non-cancer pain.
  • Recommend against long-term opioid therapy, particularly for younger age groups, as age is inversely associated with the risk of opioid use disorder and overdose.
  • Recommend against concurrent use of benzodiazepines and opioids for chronic pain.
  • If prescribing opioids, we recommend using the lowest dose and shortest duration of opioids as indicated by patient-specific risks and benefits.
  • If considering an increase in opioid dosage, we recommend reevaluation of patient-specific risks and benefits and monitoring for adverse events.

Note: Nonpharmacologic and non-opioid pharmacologic treatment options are preferred for chronic pain. Education should be provided, and available therapies should be implemented and optimized including:

  • Self-management to promote foundational health and wellness.
  • Non-opioid pharmacologic management.
  • Non-pharmacologic pain treatments:
    • Behavioral therapies (e.g., cognitive behavioral therapy).
    • Physical/movement-based therapies (e.g., physical therapy).
    • Manipulative therapies (e.g., chiropractic care).
    • Complementary and integrative health treatments (e.g., acupuncture).
  • Interventional pain care (e.g., joint injection, radiofrequency ablation).
  • Realistic expectations and limitations of medical treatment.

If the provider determines in their clinical judgement that opioid therapy may be appropriate, we recommend the following consideration checklist prior to opioid prescribing:

  • Risks do not outweigh potential benefits.
  • Patient has a condition that is:
    • Causing severe chronic pain.
    • Interfering with function and quality of life.
    • Failing to adequately respond to indicated non-pharmacologic and non-opioid pharmacologic therapy.
  • Clear and measurable functional goals are established.
  • Patient is willing and able to access adequate follow-up for prescribed opioids.
  • PDMP and Urine drug testing (UDT) are concordant with expectations (no aberrant behavior).
  • Patient is fully informed and consents to treatment with opioids.

Documentation of rationale and risk assessment should be included in the medical record.

Please consider reviewing the clinical practice guideline provider summary and abbreviated pocket card.

Quality of Care Reviews

Quality of care reviews are performed quarterly with the intent to maintain the same standard of care requirements around opioid safety for both VA and non-VA purchased care providers which may be stricter than state/local regulations. Section 131 of the Mission Act requires evaluating compliance of contracted providers with safe opioid prescribing practices. The legislation outlines that, “if VA determines that a community provider is not complying with the Opioid Safety Initiative, VA is authorized to refuse authorization of care by such provider and direct their removal from the community care network.” VA values its non-VA purchased care partners and is committed to making this process completely transparent.

The OSI dashboard is used to perform data-based risk reports evaluating the following metrics around opioid prescribing:

  • Opioid and benzodiazepine combinations
  • Morphine equivalent daily dose (MEDD) ≥ 90
  • New long-term opioid therapy (LTOT)

From these metrics, a list of providers is generated for review by VA facility staff with the aim to review the highest risk providers and risk to Veteran patients. If additional clinical review is determined to be appropriate, then clinical staff with pain expertise will review medical records to determine appropriateness of care, which could include, but not be limited to, filing a potential quality issue (PQI) with the Third-Party Administrator. Among others, these four critical elements are standard opioid risk mitigation strategies used to define the minimum standard of quality for opioid prescribing:

    1. Signed consent for long-term opioid therapy (per guidance in VHA Directive 1005-Informed Consent for Long-Term Opioid Therapy for Pain)
    2. Urine drug testing (per guidance in VA/DoD Clinical Practice Guidelines-Management of Opioid Therapy for Chronic Pain).
    3. Prescription drug monitoring program (PDMP) report or evidence/documentation of PDMP query (at initiation and per guidance in VHA Directive 1306-Querying State Prescription Drug Monitoring Programs, unless the provider’s state licensing requirements are more stringent).
    4. Prescription for naloxone or evidence of offering a prescription for naloxone (or as determined by state law).

Clinical reviewers are directed to review available documentation for indication and rationale for initiating and continuing opioid prescribing in available clinical documentation.

Requirements for the Non-VA Community Provider

  • With respect to contractual requirements:
    • Submit all prescribed non-urgent/non-emergent medications to VA for dispensing as part of the health care treatment authorized by VA (VHA National Formulary Handbook).
    • Send medical records to VA within 30 days of initial pain consultation or episode of care.
  • Review and sign the receipt of the Opioid Safety Initiative (OSI) and evidence-based guidelines included within this module.

Additional Resources

General/Routine Prescriptions

VA handles all general/routine medication fulfillments directly. To prescribe routine, non-urgent/non-emergent medicine:

  • Prescribe the medicine in accordance with VA’s National Formulary.
  • Fax both the prescription and a copy of the approved referral/authorization to your local VA Pharmacy for processing and fulfillment within one hour of seeing the Veteran.
  • The Veteran may pick up the medicine at the VA Pharmacy or an ESI pharmacy.
  • Do NOT dispense medication samples to Veterans.
  • The provider must be registered with the state’s prescription monitoring program.

If the Veteran needs a medication that’s NOT on VA’s National Formulary, providers will need to take a few additional steps before prescribing:

  • Contact the local VAMC and ask for a Formulary Request Review Form. Fill out the form and return it to the VAMC.
  • VA will either approve or deny the request.
  • If approved, continue prescribing the medication as described above.

Urgent/Emergent Medicine

When there is an urgent/emergent need to start a medication and it is not possible to fill the prescription at a VA Pharmacy, the provider may write a prescription for up to a maximum 14-day supply (without refills).

  • Send the prescription and a copy of the approved referral/authorization to an ESI retail pharmacy, preferably through the Surescripts e-Prescribing tool. To learn more about Surescripts and to register, go to the website.
  • When it is medically necessary to continue the medicine beyond the initial 14-day supply, write a second prescription and fax it to the VA’s authorizing facility pharmacy within one hour of seeing the Veteran.
    • Providers can now utilize e-prescribing to push prescriptions to a VA Pharmacy, VA’s preferred method. VA’s next preferred method is via fax.

Providers must check with their state’s prescription monitoring program for any controlled substance utilization prior to writing any controlled substance prescription for a Veteran to ensure appropriate opioid/controlled substance use.

Veterans who consent to participate in Human Subject Research studies and are enrolled in clinical trials CANNOT be authorized for those services under CCN. Veterans must be referred back to their respective Non-VA Care Office for the administration and coordination of non-VA care associated with clinical trials.

What to Include in All Prescriptions

VA requires that prescribing providers under CCN include the following information for prescriptions:

  • Provider’s Name (Family, Given, Middle Suffix) Provider Name Suffix (e.g., Sr., Jr., II. III.)
  • Provider’s National Provider Identifier (NPI)
  • Provider’s Tax ID Number (TIN)
  • Provider’s personal DEA Number and expiration date (not a generic facility number)
  • Provider’s office address
  • Provider’s office phone and additional phone number
  • Provider’s fax number (if applicable)
  • Provider’s discipline (e.g., physician, physician assistant, nurse practitioner)

Durable Medical Equipment (DME)

VA is the primary resource for all routine DME for Veterans. For urgent or emergent care, providers may directly supply Veterans with urgent/emergent DME and TriWest will reimburse providers. Urgent or emergent DME examples include: splints, crutches, canes, slings, or soft collars.

To Order Non-Urgent or Non-Emergent DME

To have routine DME (to include eyeglasses) authorized and provided to the Veteran, first complete the Community Care Provider – Request for Service form (VA form 10-10172).

An RFS form must be fully completed to include the DME section and, if ordering eyeglasses, the measurement for frames. After completing the RFS form, fax it to the authorizing VAMC within 24 hours. VA will then directly coordinate the DME between the provider and the Veteran.

Do NOT dispense non-urgent or non-emergent DME out of your office unless you receive VA approval.

Requests for exceptions to this requirement may be considered under special circumstances.

All DME and medical device prescriptions must include the following information:

  • Date of Request
  • Description and HCPCS Code for each prescribed item
  • Detailed information (brand, make, model, part number, etc.)
  • Diagnosis and International Classification of Diseases (ICD-10 Code(s))
  • Item delivery location/address
  • Expected delivery date
  • Medical Justification for each prescribed item (if a specific brand/model/product is prescribed)
  • Medical provider’s signature
  • Patient education was completed or mailed to provider to finalize education
  • Patient’s date of birth
  • Patient’s full name
  • Patient’s last 4 digits of Social Security Number (SSN)
  • Patient’s MVI ICN
  • Prescribing provider’s address
  • Prescribing provider’s fax number
  • Prescribing provider’s full name
  • Prescribing provider’s phone number

Providers are responsible for all necessary DME follow-up care, including patient education, training, fitting, and adjustment for the prescribed item. VA will procure and send the DME to the prescribing provider, unless specified otherwise.

VA reserves the right to issue comparable, functionally equivalent DME and Medical Devices to what is prescribed by the provider.

Hearing Aids: Submit prescriptions for hearing aids to VA for review and fulfillment. Providers must provide VA with initial testing results related to potential hearing aid needs. Providers cannot purchase or provide hearing aids under this contract. VA will provide information for the hearing aid manufacturers that have current contracts with VA.

Home Oxygen: Submit requests for home oxygen to VA for review and fulfillment. Providers must provide definitive testing results related to potential home oxygen needs and detailed home oxygen prescriptions. Providers cannot purchase or provide home oxygen equipment or supplies under this contract.

Oral Appliance Therapy: TriWest shall provide the capability for eligible Veterans to receive Oral Appliance Therapy (OAT) for obstructive sleep apnea through the Dental Network (managed by Delta Dental). OAT is classified as medical treatment for a medical disorder, obstructive sleep apnea, which is provided by a licensed dentist under CCN.

To order urgent or emergent DME:

  • DME must be provided to a Veteran by a treating physician, facility, or DME supplier at the time of treatment and before the Veteran leaves the provider’s care site. A pre-approved referral/authorization for urgent/ emergent DME is NOT required.
  • Bill TriWest for the urgent or emergent DME and TriWest will reimburse according to the provider contract.
  • Failure to plan or coordinate DME needs in advance of a scheduled procedure does not constitute an urgent or emergent need.
  • Any supplied DME must include follow-up care, patient education, training, fitting, and adjustment for the prescribed item as part of the supplier’s responsibility.
  • DME rentals are only covered for the first 30 days. TriWest will not pay for DME rentals beyond the initial 30 days. Providers must submit a Community Care Provider – Request for Service form in advance to VA if the rental is required beyond 30 days to ensure proper care coordination and no disruption to rental services. The Request for Service (RFS) must be signed by the ordering provider and must include supporting medical documentation.

If authorized, no rentals are to exceed 30 days.