Blue Cross Blue Shield MA Opioid Prior Auth Coverage

Coverage Criteria

Short-Acting Opioid Coverage

Short-acting opioids are covered when one of the following applies or when ALL of the listed criteria are met:

Short-acting opioid coverage exceptions: Member has a diagnosis of cancer or Sickle Cell disease OR the prescription is written by an oncologist, palliative care prescriber, pain management specialist, or oncology prescriber OR the member is receiving opioids as part of palliative care.

[[chunk 10]]

Short-acting opioid coverage general criteria: After the initial three prescriptions (or an excess of 21 days within 60 days) prior authorization is required and the prescriber must certify: an active treatment plan with a specific treatment objective and use of other pharmacologic and non-pharmacologic therapies as appropriate; a written/signed agreement between prescriber and patient addressing prescription management, diversion, and other substances; documented informed consent and an addiction risk assessment; and agreement on a prescribing group and preferred pharmacy chain.

[[chunk 11]]

Non-formulary short-acting opioids: Must meet the above prior authorization criteria AND the member must have had previous treatment failure with or a contraindication to two covered formulary alternatives; if approved, prior authorization may be granted for up to one year and may be limited to the specific opioid requested.

[[chunk 11]]

Long-Acting Opioid Coverage

Long-acting opioids are covered when any of the following apply, or when ALL of the subsequent criteria are met:

Long-acting opioid coverage exceptions: Member has a diagnosis of cancer or Sickle Cell Disease OR the prescription is written by an oncologist, palliative care prescriber, pain management specialist, or oncology prescriber OR the member is receiving opioids as part of palliative care.

[[chunk 12]]

Long-acting opioid general criteria: Prescriber certifies there is an active treatment plan that includes a specific treatment objective and use of other pharmacologic and non-pharmacologic therapies as appropriate; there has been previous treatment failure with a short-acting opioid within the previous 60 days; documented informed consent and an addiction risk assessment have been completed; a prescribing group and preferred pharmacy chain have been agreed upon; and a written/signed agreement between prescriber and patient addressing prescription management, diversion, and other substances exists.

[[chunk 13]]

Non-formulary long-acting opioids: Must meet the above criteria AND have previous treatment failure with or a contraindication to two covered formulary alternatives; if approved, prior authorization may be granted for up to one year and may be limited to the specific opioid requested.

90 MME Safety Edit Exceptions

90 MME Safety Edit exception criteria

Exceptions to 90 MME safety edit: Authorization for coverage may be approved for up to one year if ANY of the following are met: the member is receiving palliative care; the member has a diagnosis of cancer; the prescription is written by an oncologist, palliative care prescriber, or pain management specialist; OR the prescriber states that, based on the patient's clinical circumstances, the amount of opioid prescribed (>= 90 MME/day cumulative) is warranted to adequately manage the patient's pain.>= 90 MME/day

[[chunk 14]]

Non‑formulary opioid medications are not covered unless a formulary exception has been approved. For both short‑acting and long‑acting opioids, approvals for non‑formulary agents require that the member has had prior treatment failure with or a contraindication to two covered formulary alternatives, in addition to meeting the policy’s other documentation and clinical criteria. When approved, prior authorization may be granted for up to one (1) year and may be limited to the specific opioid requested.

Use beyond the initial supply is not covered without meeting the policy’s prior authorization criteria and required documentation. For short‑acting formulary opioids, an initial single 7‑day supply and up to two additional 7‑day supplies within 60 days (total up to three prescriptions/21 days within 60 days) may be covered without prior authorization. After the initial three prescriptions or an excess of 21 days within 60 days, prior authorization is required to continue therapy.

Prior authorization requests must include prescriber certification of an active treatment plan with specific treatment objectives, a written/signed opioid agreement addressing prescription management and diversion, documented informed consent and an addiction risk assessment, and agreement on the prescribing group and preferred pharmacy. Failure to provide these required documents or to meet the stated clinical criteria means coverage for continued opioid therapy is not supported.

Initial Therapy - Short-Acting

Initial short-acting opioid supply without prior authorization

Initial supply without prior authorization: One initial 7-day supply of short-acting formulary opioids may be covered without prior authorization. Up to two additional 7-day supplies (for a total of up to three prescriptions/21 days) within 60 days of the original prescription may be covered without prior authorization.<= 21 days within 60 days

[[chunk 11]]

Continuation Therapy

Authorization duration and continuation rules

Continuation after approval: If prior authorization is granted, authorization will be issued for up to one year for the specific opioid requested; authorization may be limited to the specific opioid and continuation requires ongoing compliance with the documented treatment plan, signed patient agreement, informed consent and addiction risk assessment, and agreement on prescribing group and preferred pharmacy.

[[chunk 11],[chunk 13]]

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for additional short-acting opioid treatment after the initial allowed supply limits are exceeded. We may cover up to two additional 7-day supplies of short-acting formulary opioids within 60 days of the original prescription without prior authorization, and we may cover one initial 7-day supply without prior authorization. After the initial three prescriptions or an excess of 21 days within 60 days, prior authorization is required to cover additional short-acting formulary opioids within 60 days of the original prescription.

Initial coverage without prior authorization: up to one initial 7-day supply of a short-acting formulary opioid.
Additional without prior authorization: up to two additional 7-day supplies within 60 days of the original prescription.
Trigger for prior authorization: receipt of more than three prescriptions OR cumulative supply exceeding 21 days within a 60-day period.

Step Therapy

Step Therapy and Formulary Exceptions

Step therapy and formulary status apply per the policy medication chart. Non-formulary short-acting or long-acting opioids require a formulary exception request and supporting documentation demonstrating prior treatment failure or contraindication to two covered formulary alternatives.

Quantity Limits and Safety Edits

Short-acting formulary opioids — initial supply and additional supplies

Initial supply without prior authorizationOne initial 7-day supply of short-acting formulary opioids may be covered without prior authorization.

Additional short-acting supplies without prior authorizationUp to two additional 7-day supplies (total up to three prescriptions / 21 days) within 60 days of the original prescription may be covered without prior authorization.

Prior authorization triggerAfter the initial three prescriptions or an excess of 21 days within 60 days, prior authorization is required for further short-acting opioid treatment.

Non-formulary short-acting opioidsNon-formulary requests must meet the above criteria and the member must have had prior failure with or contraindication to two covered formulary alternatives.

Authorization duration if approvedIf approved, prior authorization may be granted for up to one year and may be limited to the specific opioid requested.

Coding and Dose Thresholds

Opioid daily dose safety threshold (MME)

Opioid daily dose safety threshold>= 90 MME per day

Purpose of thresholdReal-time, point-of-service opioid safety edit to prevent unsafe dosing at dispensing.

Clinical guidanceThreshold aligns with CDC guidance to avoid increasing dosages to or above 90 MME/day without careful justification.

Step Therapy and Formulary Status

Policy instruction	Details / action
Follow formulary and step status per medication chart
Refer to the policy medication chart for each agent's formulary and step therapy designation; pharmacy operations manages exceptions and formulary‑exception requests (see Pharmacy Operations contact information).

Site of Care and Benefit Applicability

Note

Submit pharmacy requests to BCBSMA Pharmacy Operations for outpatient retail claims

Policy applies to outpatient retail pharmacy; requests for medical-benefit coverage or exceptions may be submitted to BCBSMA Pharmacy Operations via phone, fax, or the Prior Authorization/Formulary Exception form as specified in the policy.

Submit outpatient retail pharmacy prior authorization or formulary exception requests to BCBSMA Pharmacy Operations (Tel: 1-800-366-7778; Fax: 1-800-583-6289) or use the attached form.
Ensure the member has pharmacy benefits under their subscriber certificate when submitting pharmacy requests.

Definitions

Agent for opioid dependence — use with opioids

AgentBuprenorphine HCl with naloxone

IndicationIndicated for treatment of opioid dependence (opioid use disorder).

Concomitant use with opioidsShould not be used concomitantly with opioids because concomitant use increases toxicity risk; exceptions (e.g., short-term perioperative use) may exist and should be part of OUD treatment planning.

Standardized opioid dosing measure (MME)

Measure nameMorphine Milligram Equivalent (MME)

Use in policyStandardized measure used to calculate cumulative opioid dose for the 90 MME/day safety edit.

Background

Opioids are effective for pain relief but carry significant risks, including dependence, addiction, and diversion. Best practices incorporated into this policy include obtaining informed consent, performing an addiction risk assessment, documenting an active treatment plan with explicit goals and use of other pharmacologic and non‑pharmacologic therapies as appropriate, and establishing a written opioid agreement between prescriber and patient. These measures support safe prescribing and are required documentation when prior authorization is requested for continued opioid therapy.

OpenPayer

Opioid prior authorization and dosing policy

Coverage Criteria

Initial Therapy - Short-Acting

Continuation Therapy

Provider Actions and Requirements

Quantity Limits and Safety Edits

Coding and Dose Thresholds

Step Therapy and Formulary Status

Site of Care and Benefit Applicability

Definitions

Background