Blue Cross Blue Shield MA opioid Prior Auth Policy Update

Coverage Criteria

Short-Acting Opioids

Covered when ANY of the following are met

Oncology/Sickle Cell/Palliative: Member has a diagnosis of cancer or Sickle Cell disease OR prescription is written by an oncologist, palliative care prescriber, pain management specialist, or oncology prescriber OR member is receiving opioids as part of palliative care.

Supports initial coverage without PA or for continued coverage per policy

General chronic use requiring PA: After up to three initial 7-day supplies (or >21 days in 60 days), prior authorization is required and will be approved if prescriber certifies an active treatment plan; informed consent and addiction risk assessment performed; written prescriber–patient agreement exists; and prescriber/patient agree on prescriber group and preferred pharmacy chain.

PA if continued therapy beyond initial supplies

Non-formulary short-acting: In addition to the above PA requirements, member must have previous treatment failure with or contraindication to two covered formulary alternatives.

Non-formulary exceptions require documented failures

Long-Acting Opioids

Covered when ANY of the following are met

Oncology/Sickle Cell/Palliative/Prescriber-specialist: Member has a diagnosis of cancer or Sickle Cell Disease OR prescription is written by an oncologist, palliative care prescriber, pain management specialist, or oncology prescriber OR member is receiving opioids as part of palliative care.

These conditions allow coverage of long-acting opioids

Long-acting for chronic pain: There has been previous treatment failure with a short-acting opioid within the previous 60 days AND prescriber certifies an active treatment plan; informed consent and addiction risk assessment performed; written prescriber–patient agreement exists; and prescriber/patient agree on prescriber group and preferred pharmacy chain.

Required for approval when not oncology/palliative

Non-formulary long-acting: Requests must meet the long-acting criteria above and have previous treatment failure with or a contraindication to two covered formulary alternatives.

Non-formulary exceptions require documented failures

90 MME Safety Edit Exception Criteria

Authorization for doses >=90 MME/day will be approved if ONE of the following is met

90MME exception: Member has a diagnosis of cancer OR member is receiving opioids as part of palliative care OR prescription is written by an oncologist, palliative care prescriber, or pain management specialist OR prescriber documents that, based on the patient's clinical circumstances, the prescribed amount is warranted to adequately manage the patient's pain.>= 90 MME/day

Exception can be requested through BCBSMA Pharmacy Operations when pharmacist safety edit cannot be resolved at point of sale

This policy applies to BCBSMA commercial pharmacy plans and does NOT apply to Medicare Advantage. Formularly status, step therapy designations, and whether specific products are handled under this policy are detailed in the formulary charts and tables referenced in the document; reviewers should consult those charts for the current formulary listing and specific product handling.

The formulary charts list many individual branded and generic short‑acting and long‑acting opioid products and indicate the policy’s application to each product (for example, items such as Apadaz, Dilaudid, Duramorph, Endocet, fentanyl products, Butrans, and various ER products are shown in the tables). Use the charts to determine current standard/formulary status and any product‑specific prior authorization or step requirements.

The policy history documents periodic maintenance of the policy including removal of discontinued drugs and elimination of obsolete brands. The 5/2026 annual review entry states: "Formatting, reference, and literature update. Removed obsolete brands. No changes to criteria." Historical entries (2017–2024) list additions and removals of specific products and procedural updates but the excerpt does not include separate, explicit exclusion wording beyond those historical actions.

No content specified in the provided excerpt for this section.

Coding & Safety Thresholds

Morphine Milligram Equivalent threshold — inv-07

Threshold>= 90 MME per day

Trigger typePharmacy point-of-sale safety edit activated when cumulative opioid dose across all prescriptions reaches or exceeds 90 MME/day

Effective date of safety edit implementationEffective July 1, 2021

Exception routePrescriber can request an exception through BCBSMA Pharmacy Operations if pharmacist cannot resolve the safety edit at point of sale

Provider Actions / Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required for ongoing short-acting opioids after initial supply and for long-acting opioids not meeting exempt criteria. Short-acting formulary opioids may be covered without prior authorization for up to an initial 7‑day supply and up to two additional 7‑day supplies within 60 days (total up to 21 days in 60 days). After three short-acting prescriptions or exceeding 21 days of supply within 60 days, prior authorization is required to continue coverage within the 60‑day window. Long-acting opioids require prior authorization unless the request meets specific exceptions (see callout on long-acting criteria). If approved, prior authorization is generally granted for up to one (1) year for the specific opioid requested; authorizations cover only the specific opioid and non-formulary medications require a formulary exception.

Short-acting formulary opioids: up to an initial 7-day supply without PA
Up to two additional 7-day short-acting supplies within 60 days without PA
PA required after initial three prescriptions or >21 days supply in 60 days
PA approvals typically granted up to 1 year and are opioid-specific
Non-formulary medications require PA + prior failure/contraindication to two formulary alternatives and may need a formulary exception

Initial Therapy Criteria

Initial short-acting coverage

Initial short-acting opioid coverage without prior authorization

Initial short-acting supply: We may cover up to one initial 7-day supply without prior authorization and up to two additional 7-day supplies within 60 days (total up to 21 days) without prior authorization.

After these initial supplies, prior authorization is required for further short-acting opioid coverage

Continuation Therapy Criteria

Continuation therapy rules

Conditions for continuation of opioid therapy after initial supplies or for high-dose therapy

Continuation after short-acting initial supply: After initial three 7-day supplies or >21 days in 60 days, prescriber must meet PA documentation requirements (certify an active treatment plan; informed consent and addiction risk assessment; a written/signed prescriber–patient agreement; and agreement on prescriber group and preferred pharmacy chain) for continued coverage; PA may be granted for up to 1 year.

Continuation for long-acting therapy: Long-acting opioids require previous treatment failure with a short-acting opioid within the prior 60 days and the PA documentation items above; PA may be granted for up to 1 year.

High-dose continuation (>=90 MME): Authorization for doses >=90 MME/day will be approved if member has cancer, is receiving opioids as part of palliative care, the prescription is written by an oncologist/palliative care prescriber/pain management specialist, or the prescriber documents that the dose is clinically warranted; exception requests may be submitted to BCBSMA Pharmacy Operations if the pharmacist safety edit is unresolved.

Step Therapy Requirements

Requirement	Details
Documented trials of formulary alternatives
For non-formulary long-acting opioids: member must have previous treatment failure with or a contraindication to at least two covered formulary alternatives (Appendix: formulary status '1' requirement).

Date	Policy history note
5/2026
Annual Review: Formatting, reference, and literature update. Removed obsolete brands. No changes to criteria.
7/2021
Updated to add 90 MME safety edit and make Oxycontin nonpreferred.
11/2020
Clarified we will only approve authorizations for specific opioids and not for groups of opioids.
7/2012
New Policy, effective 7/1/12.

Background

Opioids provide effective analgesia but carry well‑recognized risks including addiction, misuse, and diversion; the policy emphasizes balancing pain management with safety controls. The document highlights the need for an active treatment plan and informed consent processes, including an addiction risk assessment and a written prescriber–patient agreement, as prerequisites for continued opioid therapy beyond initial short supplies.

The policy incorporates safety measures such as a pharmacy point‑of‑sale edit at ≥ 90 MME/day to trigger pharmacist and prescriber review, and it requires prescribers to document clinical justification or meet specialist/oncology/palliative care exceptions when higher doses are needed. For continuation of therapy, prior authorization may be granted for up to 1 year when the required documentation (treatment plan, informed consent, signed agreement, and prescriber/group/pharmacy selection) is provided.

Definitions

Treatment agreement — inv-17

DefinitionWritten/signed agreement between prescriber and patient addressing prescription management, diversion, and use of other substances

PurposeDocuments treatment expectations, supports informed consent and addiction risk management

Associated requirementsPart of required documentation for continued opioid therapy and prior authorization (certify active treatment plan, informed consent, addiction risk assessment)

90 MME safety edit — inv-18

Pharmacist actionDispensing pharmacist receives an alert and must consult with prescriber before proceeding; pharmacist may override with a code or exercise professional judgment to not dispense

If unresolved at point of salePrescriber may request an exception for coverage through BCBSMA Pharmacy Operations

Revision History

2026-05annual_reviewLatest

Annual review: formatting, reference and literature updates; removed obsolete brands; no changes to coverage criteria.

2024-11clarification

Clarified covered diagnoses in the policy.

2023-07reformat

OpenPayer

Opioid medication prior authorization and coverage