Healthy Blue Opioid Misuse Prevention Program Description
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Describes Healthy Blue and Healthy Blue Care Together's program to monitor and reduce opioid misuse for North Carolina Medicaid members, including utilization management, lock-in program operations, naloxone strategies, and care coordination. Affects prescribers, pharmacies, and eligible members in NC Medicaid.
No material clinical or coverage changes in this revision.
Lock-In and Monitoring Criteria
Lock-In Program Enrollment Criteria
Members may be enrolled into the lock-in program when ANY of the following criteria are met:
Subject to applicable NC contract and specific criteria.
Controlled Substance Utilization Monitoring (CSUM) Criteria
CSUM high-dose alert and monitoring criteria:
Prescribers will be encouraged to prescribe naloxone for members taking high doses; interventions include prescriber and/or member engagement to educate, coordinate care, and reduce risk of overutilization.
Members are automatically exempt from enrollment in the lock‑in program when any one of the following applies: age under 18 years; residing in a skilled nursing facility; receiving hospice services; prescribed buprenorphine products specifically indicated for treatment of opioid use disorder (OUD); a cancer diagnosis within the past year; a diagnosis of sickle cell disease; or when the member is receiving medically necessary, frequent/complex care for a life‑threatening condition as determined by Healthy Blue.
Dose Thresholds and Definitions
Prescriber and Pharmacy Requirements
Prior authorization exceptions and requirements
Prior authorization is not required for beneficiaries with a diagnosis of pain secondary to cancer and is not required for preferred short-acting opioids up to the equivalent daily maximum dose of 90 MME/day for beneficiaries with sickle cell disease. However, prior authorization is required for non-preferred opioids on the State PDL regardless of dose, and the plan will maintain prior authorization criteria consistent with Department requirements for short- and long-acting opioid analgesics.
- No PA for cancer-related pain (diagnosis-based exemption).
- No PA for preferred short-acting opioids up to 90 MME/day for members with sickle cell disease.
- PA required for non-preferred opioids on the PDL regardless of dose.
- PA criteria will align with Department requirements for short- and long-acting opioids.
Promote non-opioid alternatives and align with State PDL
The program supports promotion of non-opioid alternatives in accordance with the State formulary and STOP Act–related requirements, and it will maintain prior authorization criteria consistent with Department requirements to ensure alignment with the State PDL.
- Supports promotion of alternatives to opioids according to the State formulary (per STOP Act requirements).
- Maintains PA criteria consistent with Department requirements to ensure prior authorization consistency with the PDL.
Enroll lock-in prescribers in NC Medicaid and document assignment
Prescribers assigned as lock-in providers must be enrolled in NC Medicaid and agree to provide care under the program guidelines; claims for lock-in members are reimbursed only when prescriptions are written by the assigned prescriber(s) and filled at the assigned pharmacy.
- Assigned prescribers must be enrolled in NC Medicaid and accept responsibility for the member under RMLP guidelines.
- Claims are reimbursed only when written by the assigned prescriber(s) and filled at the assigned lock-in pharmacy.
Claims will reject if not written/filled by assigned prescriber or pharmacy
If a restricted medication is filled at a non-designated pharmacy or written by a non-designated prescriber for a member enrolled in the RMLP, the claim will reject for pharmacy or prescriber lock-in and will not be paid unless an advance authorization is obtained.
- Claims for restricted medications will reject at point of sale if not from the assigned prescriber or pharmacy.
- Reimbursement will be denied unless prior authorization is obtained in advance for fills outside assigned providers.
Program Purpose and Scope
The program is designed to prevent opioid overuse, identify members at elevated risk from prescription opioid use, improve access to substance use disorder treatment and recovery services, and coordinate care for members with chronic high‑risk opioid use. Interventions include monitoring high‑dose opioid prescribing, issuing alerts to prescribers for elevated daily morphine milligram equivalents, promoting naloxone distribution, providing provider education, and linking members to integrated behavioral health and treatment resources.
This initiative aligns with the North Carolina Opioid and Substance Use Action Plan and focuses on early identification of risk through Controlled Substance Utilization Monitoring (CSUM), enrollment in a Recipient Management Lock‑In Program for defined utilization triggers, and coordination of care to support appropriate pain management and medication‑assisted treatment when indicated.
Key Terms
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