Opioid Coverage and Prior Authorization Policy
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Defines prior authorization, safety edits, and coverage criteria for short-acting and long-acting opioid prescriptions for Blue Cross and Blue Shield of Louisiana members; applies to prescribers and pharmacies handling member opioid prescriptions.
No material clinical or coverage changes in this revision.
Coverage Criteria
Short-acting opioid prior authorization
Prior authorization is required unless the requested opioid is used for cancer pain or end-of-life care, OR when ALL of the following are met:
Claims history or provider information may establish exception
All listed conditions must be met
Long-acting opioid prior authorization (new users)
Prior authorization required for new users unless the requested opioid is used to treat cancer pain or end-of-life care, OR when ALL of the following are met:
Claims history or provider information may establish exception
All listed conditions must be met; agent-specific step requirements apply
Coverage decisions recognize exceptions for cancer-related pain and end-of-life care. When the requested opioid is being used to treat cancer pain or for end-of-life care, the prior authorization requirements do not apply if the member’s claims history or information provided by the treating provider establishes that exception.
When an exception is not established, prior authorization requirements apply. For short-acting opioids this includes fills longer than a 7-day supply or a cumulative supply exceeding 21 days within 60 days. For long-acting opioids, prior authorization is required for new users. Providers should submit claims history or attestations in the medical record as needed to document cancer or end-of-life status so the exception can be evaluated.
Coding and Thresholds
Provider Actions and Requirements
Prior authorization required for certain short- and long-acting opioids
Prior authorization is required for short-acting opioid fills that exceed a 7-day supply or a cumulative 21-day supply within 60 days, and for new-user long-acting opioid prescriptions; this requirement does not apply when the requested opioid is used to treat cancer pain or for end-of-life care (exceptions may be established from claims history or provider information). Providers must obtain PA before dispensing when these thresholds or new-user long-acting opioid requests apply to avoid claim denial or delay.
- Short-acting opioids: PA required for fills longer than a 7‑day supply or cumulative >21 days within 60 days.
- Long-acting opioids: PA required for new users.
- Cancer pain and end-of-life care are exceptions when supported by claims or provider information.
Step therapy: required trials and failures for specific opioid agents
For specified products the prescriber must document trial-and-failure of alternative opioid agents before approval: levorphanol 2 mg/3 mg tablets require failure of TWO listed short-acting opioids; many long-acting agents require failure of at least TWO listed long-acting alternatives; Butrans patch specifically requires failure of the generic buprenorphine patch AND Belbuca, unless clinical evidence or history indicates ineffectiveness or adverse reaction.
- Levorphanol 2 mg/3 mg tablets: try and fail TWO specified short-acting products (listed in policy) unless contraindicated.
- Several long-acting agents (e.g., Arymo ER, Hysingla ER, Duragesic, MS Contin, Xartemis XR, Xtampza ER, Zohydro ER, etc.): try and fail at least TWO listed long-acting opioid alternatives unless contraindicated.
- Butrans patch (all strengths): must try and fail generic buprenorphine patch AND Belbuca unless clinical evidence/history justifies exception.
Required documentation to support prior authorization requests
Prescribers must document and certify in the medical record that an active multimodal treatment plan is in place, that a patient–prescriber agreement addressing prescription management/diversion/pharmacy shopping/substance use is documented, and that an addiction risk assessment has been completed; additionally, document trials and failures of required alternative agents when step therapy applies.
- Certify active treatment plan including other pharmacological and nonpharmacological agents.
- Document patient–prescriber agreement addressing prescription management, diversion, doctor/pharmacy shopping, and substance use.
- Complete and document an addiction risk assessment.
- Document trials and failures of specified alternative opioids when required by agent-specific criteria.
Denial triggers: supply thresholds and unmet PA/step requirements
Requests will be denied if they exceed short-acting thresholds (fills longer than a 7‑day supply or cumulative >21 days within 60 days) or if a long-acting opioid is initiated for a new user without meeting the PA criteria or required step-therapy exceptions.
- Exceeding short-acting opioid limits—>7 days per fill or >21 days cumulative in 60 days—triggers denial unless exception applies.
- Initiation of long-acting opioids for new users without meeting all PA criteria (including required trials where applicable) can result in denial.
Definitions
Background
Opioid misuse is an ongoing statewide concern. In response, Blue Cross and Blue Shield of Louisiana has implemented opioid coverage controls designed to limit initiation to chronic opioid use and to reduce overall opioid supply, aligning coverage practices with clinical guidance and state efforts to improve prescribing safety.
These controls include safety edits and prior authorization requirements for both short-acting and long-acting opioids — for example, prior authorization is required for short-acting opioid fills that exceed a 7-day supply or a cumulative supply of 21 days within 60 days, and for new users of long-acting opioid products. Additional information about drug coverage and the plan’s Covered Drug List is available at the payer’s member resources.
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