Impacted: Mid-market book of business

Overview

At Prime Therapeutics (Prime), we develop holistic solutions to help our clients and their members solve their most complex pharmacy problems. One of today's biggest challenges is minimizing the misuse and abuse of opioid drugs. Our point-of-sale (POS) utliization management (UM) program helps to regulate member opioid fills. This helps to ensure members receive an appropriate amount of medicine, helping to reduce negative outcomes.

Next steps

In response to member and client feedback, effective Oct. 1, 2025, two updates will be made to the short opioid POS UM program:

1. Prime will no longer limit one short acting opioid (SAO) per 29 days.
2. Prime will no longer restrict the dose dispensed based on morphine milligram equivalents (MME). 

The short opioid POS UM program will continue to focus on the limitation of opioids dispensed to members who haven’t used opioids recently or regularly.

Why it matters

Reporting has shown that the limitation of one SAO per 29 days has proven to be more disruptive to members, especially those who haven’t used opioids recently or regularly. In addition, medical guidelines have indicated MME thresholds should only serve as guidance for physicians. The opioid formulary quantity limits developed by Prime aligns with the FDA dosing and limitation requirements, which are supported by medical guidelines.

Questions

Please reach out to your Prime account executive.