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Opioid Management Program Effective April 1, 2018

January 11, 2018

BlueCross BlueShield of South Carolina and BlueChoice® HealthPlan are dedicated to reducing the over-prescribing of opioids to ultimately help reduce the number of new opioid addicts and deaths. Our Pharmacy & Therapeutics (P&T) Committee has developed an Opioid Management Program to begin April 1, 2018. The P&T Committee based its recommendations and decisions on the guidance set forth by the Centers for Disease Control and Prevention (CDC). The program will consist of daily quantity limits specific to each drug, along with prior authorization for certain prescribing situations.

A few highlights of the program include:

  • An initial days supply fill limit for all short acting/immediate release (IR) opioids.
  • Specific day supply initial fill limit for all long acting/extended release (ER) opioids provided the patients’ prescription history has proof of a previous fill of an IR opioid prescription in the past 90 days.
  • All daily supply limits for IR and ER opioids are calculated based on 90 MME (morphine milligram equivalents) a day. Requests for quantities above 90 MME a day will require prior authorization.
  • If the request for quantities above 90 MME is approved, patients will be allowed to fill up to a max of 120 MME per day.
  • Prior authorization criteria will be implemented to manage the allowed appropriate daily limits and to encourage ongoing physician monitoring of patients on opioid therapy.
  • The program applies to all BlueCross and BlueChoice® members. The program does not apply to Affordable Care Act (ACA) members and plans, as these members are subject to a similar program administered by CVS Caremark. CVS Caremark is a division of CVS/Health, an independent company that provides pharmacy services on behalf of BlueCross and BlueChoice.
  • Patients undergoing cancer treatment, palliative and end-of-life care will be exempt from the program requirements.

OTHER PROGRAM DETAILS

IR For Acute/Chronic Pain

  • All IR opioid agents will have a seven-day supply (90 MME a day) initial fill limit in 30 days.
  • If a member has a seven-day or greater supply of an IR or ER opioid in his or her claims history in the past 90 days, the IR opioid will be covered for up to the initial quantity limit (90 daily MMEs for 30 days).
  • The member should be evaluated and monitored for the development of opioid use disorder, and the member’s pain should be reassessed after the initial prescription or a dose increase and every three months thereafter using a validated assessment tool, such as the Current Opioid Misuse Measure (COMM). 
  • Doses greater than 90 MME per day require prior authorization. Approvals can be made for up to 120 daily MME. Requests for doses greater than 120 MME per day will be considered if an appeal is filed.
     

IR Opioid COMBINATION Products for Acute/Chronic Pain (products containing acetaminophen, ibuprofen, aspirin, other non-opioid pain medication in combination with the narcotic opioid)

  • All IR opioid combination products will have a seven-day supply (90 MME a day) initial fill limit in 30 days.
  • If a member has a seven-day or greater supply of an IR or ER opioid combination in his or her claims history in the past 90 days, the IR opioid  combination product will be covered for up to the initial quantity limit (= 90 daily MME and = 4 grams APAP or ASA and = 3200 mg ibuprofen for 30 days).
  • The member should be evaluated and monitored for the development of opioid use disorder, and the member’s pain should be reassessed after the initial prescription or a dose increase and every three months thereafter using a validated assessment tool, such as the Current Opioid Misuse Measure (COMM). 
  • Doses greater than 90 MME per day require Prior Authorization. Approvals can be made for up to 120 daily MME. Requests for doses greater than 120 MME per day will be considered if an appeal is filed.
  •  Prior Authorization requests will automatically reject for the following drugs/doses:
    • Acetaminophen does greater than four grams (4000 mg) a day
    • Aspirin does greater than four grams (4000 mg) a day
    • Ibuprofen does greater than 3200 mg a day

ER Opioid Products for Chronic Pain

  • All ER opioid agents will have a 30-day supply (90 MME a day) initial fill limit.
  • If a member does not have a seven-day supply of an IR opioid or a 30-day supply of an ER opioid within his or her claims history in the past 90 days, then a PA will be required.
  • The patient must be evaluated and monitored for the development of opioid use disorder, and the patient’s pain should be reassessed after the initial prescription or any dose increase and every three months using a validated assessment tool, such as the COMM.
  • If a larger dose is needed, a PA will be required with approval of up to 120 daily MME for 12 months.
  • Requests for doses greater than 120 MME a day will be considered if an appeal is filed.

Read more about calculating the total daily dose of opioids here. If you have questions about this bulletin, please send an email to provider.education@bcbssc.com or submit your question using the Provider Education Contact Form. As additional information, our members who will be impacted by the new quantity limits and prior authorization requirements will receive communication informing them of the new program.

BlueChoice® HealthPlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

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