Currentblue cross blue shield - louisianaPolicy N/A

Opioid prescription coverage and prior authorization rules

Coverage and prior authorization requirements for short-acting and long-acting opioid medications for Blue Cross and Blue Shield of Louisiana members, including safety edits and documentation expectations for prescribers.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyOpioid prescription coverage and prior authorization rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization for short-acting opioid fills over a 7-day supply or cumulative >21 days per 60 days and for new users of long-acting opioids unless cancer or end-of-life care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

42%+reduction in opioid prescriptions per 1,000 members since 2016

51%+reduction in opioid units per member per month since 2016

7 daysmax short-acting fill without PA

21 days/60dcumulative supply threshold for PA

Coverage Criteria for Opioid Prescriptions

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-01: Short-acting opioids — Prior authorization required when ANY of the following apply

Prior authorization required for short-acting opioids when ANY of the following apply:

Short-acting PA triggers: Requested fill longer than a 7-day supply OR cumulative fills longer than a 21-day supply within 60 days>7 days or >21 days per 60 days

Exceptions for cancer pain or end-of-life care when supported by claims history or provider information

inv-02: Long-acting opioids — Prior authorization required for new users unless cancer or end-of-life; alternative coverage conditions

Prior authorization required for long-acting opioids for new users unless cancer or end-of-life care; alternatively, covered when ALL listed criteria are met:

Long-acting PA general criteria: 1) Patient requires around-the-clock pain control; 2) Prescriber documents an active treatment plan including other pharmacologic and nonpharmacologic agents; 3) Prescriber documents a patient-prescriber agreement addressing prescription management, diversion, doctor/pharmacy shopping and use of other substances; 4) Prescriber has completed an addiction risk assessment

All four items must be documented if not cancer/end-of-life

Agent-specific step therapy: If requested drug is one of the specified branded long-acting agents, patient must have tried and failed at least TWO of the listed alternative long-acting opioids (see coding list). For Butrans or branded buprenorphine patch, patient must have tried and failed generic buprenorphine patch AND Belbuca.2 failed alternatives (or both failures for buprenorphine patch)

Enumerated branded agents and acceptable alternatives are listed in the policy coding sections

Cancer pain and end-of-life care are exceptions to the prior authorization requirements when supported by claims history or provider documentation. For other indications, prior authorization requirements differ by opioid type.

For short-acting opioids, prior authorization is required when a requested fill exceeds a 7-day supply or when cumulative fills exceed a 21-day supply within 60 days.

For long-acting opioids, prior authorization is required for new users unless the request is for cancer pain or end-of-life care. Alternatively, coverage may be authorized when all of the following are documented: 1) patient requires around-the-clock pain control; 2) prescriber documents an active treatment plan including other pharmacologic and nonpharmacologic therapies; 3) a patient–prescriber agreement addressing prescription management/diversion/shopping/other substance use is documented; and 4) an addiction risk assessment has been completed. In addition, certain branded long-acting agents require documented trials and failures of specified alternatives (see coding/step therapy requirements).

Codes, Supply Thresholds, and Related Limits

Specified long-acting agents with step requirementsmixed

Arymo ER	listed branded long-acting opioid requiring step therapy
Belbuca	listed buccal buprenorphine product with step requirements
Dolophine	brand name methadone product listed
Duragesic Patch	fentanyl patch listed
Embeda	listed long-acting opioid
Exalgo	listed long-acting opioid
Kadian	listed long-acting opioid
MS Contin	listed long-acting opioid
Nucynta ER	listed long-acting opioid
Opana ER	listed long-acting opioid

1–10 of 15

1/2

Acceptable trial alternatives for step therapymixed

generic buprenorphine patch	5 mcg, 7.5 mcg, 10 mcg, 15 mcg, 20 mcg
generic fentanyl patch	12 mcg, 25 mcg, 50 mcg, 75 mcg, 100 mcg
generic hydromorphone ER	alternative long-acting opioid
generic hydrocodone bitartrate ER	alternative long-acting opioid
Hysingla ER	alternative long-acting opioid
generic methadone	alternative long-acting opioid
generic methadose	alternative long-acting opioid
generic morphine sulfate ER	alternative long-acting opioid
generic morphine sulfate CR	alternative long-acting opioid

inv-06: Short-acting opioid supply threshold — PA required for fills >7 days OR cumulative >21 days within 60 days

Threshold triggerPrior authorization required for any short-acting opioid fill longer than a 7-day supply

Cumulative thresholdPrior authorization required for cumulative short-acting opioid supply greater than 21 days within a 60-day period

ExceptionsCertain exceptions for members with cancer or receiving end-of-life care based on claims history and/or provider information

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Short-acting opioid prior authorization

Prior authorization required for short-acting opioid fills that exceed quantity limits. Requests for fills greater than a 7-day supply, or a cumulative supply exceeding 21 days within any 60-day period, will require prior authorization. Exceptions apply for members with cancer or those receiving end-of-life care based on claims history and/or provider information.

Applies to short-acting opioids (examples: Percocet® and generics, Lortab® and generics, codeine, oxycodone).

Prior Authorization

Long-acting opioid new-user prior authorization

Prior authorization required for new users of long-acting opioids. Certain exceptions apply for members with cancer or receiving end-of-life care based on claims history and/or provider information.

Applies to long-acting opioids (examples: Butrans®, fentanyl patch, OxyContin®, MS Contin®, morphine ER, Oxycodone ER).

Step Therapy

Step therapy for specified long-acting opioids

Step therapy applies for specified long-acting opioid agents. For the following requested long-acting agents: Arymo® ER, Belbuca, Dolophine®, Duragesic® Patch, Embeda®, Exalgo®, Kadian®, MS Contin®, Nucynta™ ER, Opana® ER, branded Oxycodone ER, Xartemis® XR, Xtampza™ ER, Zohydro® ER, and Morphabond™ ER, the patient must have tried and failed at least TWO of the listed long-acting alternatives prior to approval.

Required trial-and-failure alternatives (try at least two): generic buprenorphine patch (5 mcg, 7.5 mcg, 10 mcg, 15 mcg, 20 mcg); generic fentanyl patch (12 mcg, 25 mcg, 50 mcg, 75 mcg, 100 mcg); generic hydromorphone ER; generic hydrocodone bitartrate ER; Hysingla® ER; generic methadone; generic methadose; generic morphine sulfate ER; generic morphine sulfate CR; OxyContin®.

Documentation Required

Step therapy documentation for specific long-acting agents

Step therapy documentation requirements for specific long-acting agents must be present in the medical record. For requests involving the listed long-acting agents, documentation must demonstrate trials and failures of the specified alternative long-acting opioids (see step therapy list).

If the requested drug is Butrans patch or branded Buprenorphine Patch, documentation must show trial and failure of generic buprenorphine patch and Belbuca patch.
Ensure medical record contains dates, dosages, duration, and reason for failure or intolerance for each trialed agent.

Documentation Required

Required medical record documentation

Prescribers must document an active treatment plan and a signed patient-prescriber agreement when requesting prior authorization for opioids (short-acting fills exceeding limits or long-acting new-user requests). Prescriber must also have completed an addiction risk assessment.

Active treatment plan should include other pharmacologic and nonpharmacologic therapies as appropriate.
Patient-prescriber agreement must address prescription management, diversion, doctor/pharmacy shopping, and use of other substances.

Background and Rationale

Opioid therapies carry significant risks including misuse, dependence, and transition to chronic use. This policy aims to reduce opioid initiation and total opioid exposure by applying supply limits and prior authorization rules that align coverage with clinical expectations and state requirements.

The policy implements safety edits that limit short-acting opioid supplies — a single fill beyond 7 days or aggregated supplies exceeding 21 days per 60 days trigger prior authorization — and requires more rigorous documentation and step-therapy evidence for new long-acting opioid prescriptions to ensure around-the-clock use is clinically warranted.

Definitions and Examples

inv-15: Short-acting opioids (examples provided)

Examples (nonexhaustive)Percocet and generics; Lortab and generics; codeine; oxycodone

PA trigger summaryShort-acting opioids require prior authorization when requested fill exceeds 7 days or cumulative supply exceeds 21 days per 60 days

Related safety editsPolicy also includes acetaminophen, ibuprofen, and aspirin safety edits for combination products (see full policy)

inv-16: Long-acting opioids (examples provided; new-user PA required)

Examples (listed agents)Butrans, fentanyl patch (Duragesic), OxyContin, MS Contin, morphine ER, oxycodone ER

New-user PAPrior authorization required for new users of long-acting opioids (exceptions for cancer or end-of-life care)

Agent-specific step therapyFor listed branded long-acting agents, patient must have tried and failed at least TWO specified long-acting alternatives (see step list)

Documentation requirementsPrescriber must document active treatment plan, patient-prescriber agreement, and completed addiction risk assessment