Opioid prescription coverage and prior authorization rules
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Opioid Prescriptions
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:
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:
All four items must be documented if not cancer/end-of-life
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
| 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 |
| 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 |
Provider Requirements, Prior Authorization, and Documentation
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).
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 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®.
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.
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
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