Currentblue cross blue shield - tennesseePolicy N/A

Opioid therapy (short-acting, long-acting) and MME limits

Defines prior authorization and coverage criteria for short-acting and long-acting opioid prescriptions and morphine milligram equivalent (MME) thresholds for Blue Cross Blue Shield Tennessee members.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyOpioid therapy (short-acting, long-acting) and MME limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with required documentation and attestations; authorizations for short-acting and long-acting opioids are issued for one year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7required prescriber/patient attestations for long-acting opioids

7required prescriber/patient attestations for short-acting opioids

120 mgMME prior authorization threshold (daily)

90 mgMME level prompting prescriber specialist requirement

7 daysinitial short-acting opioid limit

1 year

Policy Summary

Payerblue cross blue shield - tennessee

PolicyOpioid therapy (short-acting, long-acting) and MME limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with required documentation and attestations; authorizations for short-acting and long-acting opioids are issued for one year.

SourceLink

On This Page

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Coverage Criteria

Long-acting opioid approval

Long-acting opioids will be approved if ALL of the following are met

Long-acting opioid approval: a. Prescriber attests the patient HAS NOT received Medication-Assisted Treatment for the treatment of opioid dependence in the last 60 days

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Long-acting opioid approval: b. Prescriber attests the patient HAS NOT received a prescription for an opioid, a benzodiazepine AND a muscle relaxant in the last 60 days

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Long-acting opioid approval: c. Documentation that shows the patient's diagnosis, evaluation and medical assessment for the requested medication

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Long-acting opioid approval: d. Prescriber has completed a risk assessment for aberrant behavior associated with opioid misuse

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Long-acting opioid approval: e. A signed pain management agreement between the patient and prescriber in the past 6 months

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Long-acting opioid approval: f. Prescriber has checked the state controlled substance database in the last 90 days

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Long-acting opioid approval: g. A treatment plan is in place between the patient and provider

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Long-acting opioid approval: h. Previous treatment with short-acting opioids at the lowest possible dose

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Short-acting opioid approval

Short-acting opioids will be approved if ALL of the following are met

Short-acting opioid approval: a. Prescriber attests the patient HAS NOT received Medication-Assisted Treatment for the treatment of opioid dependence in the last 60 days

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Short-acting opioid approval: b. Prescriber attests the patient HAS NOT received a prescription for an opioid, a benzodiazepine, AND a muscle relaxant in the last 60 days

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Short-acting opioid approval: c. Prescriber attests that the member's treatment plan includes a long-acting opioid when the member has an elevated morphine milligram equivalent greater than 50 mg/day, unless contraindicated

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Short-acting opioid approval:

Criteria for >7 day short-acting opioid supply

Greater than a seven day supply of short-acting opioids will be approved if ONE of the following is met

>7 day short-acting supply: a. Patient had surgery in the last 14 days

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>7 day short-acting supply: b. Patient has suffered a severe burn or major physical trauma in the last 30 days

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>7 day short-acting supply: c. Patient is currently in a licensed health care facility

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>7 day short-acting supply: d. Patient is being seen by a pain management specialist or supervisee of a pain specialist

MME exceedance

MME policy

MME prior authorization: Prior authorization is required for members who take greater than 120 mg equivalents of morphine a day>120 mg/day

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Exclusion criteria: N/A. The source document lists "N/A" for exclusion criteria across the long-acting and short-acting opioid sections and the MME section, but it also notes that not all opioids may be covered on the member's formulary, so formulary coverage should be verified prior to authorization.

Coverage stance: Covered with criteria. Approvals require meeting the specific prescriber attestations, documentation, and monitoring requirements described in the policy for long-acting opioids, short-acting opioids, and MME exceedance.

Approvals depend on required attestations and supporting documentation. For both short-acting and long-acting opioids the prescriber must attest to recent Medication-Assisted Treatment and co-prescribing history, complete risk assessment(s), confirm a signed pain management agreement within the past 6 months, and document the patient’s diagnosis, evaluation and medical assessment. The policy also requires the prescriber to check the state controlled substance database within the last 90 days and have a treatment plan in place; these items must be present in the submitted documentation or attested to for authorization to be issued.

Coding and Thresholds

No specific CPT/HCPCS/ICD-10 codes listed in documentmixed

No codes listed

MME daily threshold for prior authorization

MME daily prior authorization threshold> 120 mg per day

Coverage duration for MME exceedance approvals180 days

Required documentation when exceeding MME limitDiagnosis, nature and intensity of pain, past and current treatments of pain, and medical necessity to exceed standard MME limit

MME level prompting inclusion of long-acting opioid in treatment plan

MME level prompting inclusion of long-acting opioid in treatment plan> 50 mg per day

Prescriber attestation requirementPrescriber must attest treatment plan includes a long-acting opioid when member's MME >50 mg/day unless contraindicated

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for initiation or continuation of short-acting and long-acting opioid prescriptions. Submit coverage reviews through CoverMyMeds in Availity or by calling 1-800-924-7141. Note: Not all opioids may be covered on the member's formulary.

Authorization duration: short-acting and long-acting opioids — 1 year; MME exceedance reviews — 180 days.
Prior authorization trigger for MME exceedance: >120 mg MME/day.

Step Therapy

Step Toward Long-Acting Therapy at MME >50 mg/day

When prescribing short-acting opioids for patients with an elevated morphine milligram equivalent (MME) >50 mg/day, the prescriber must attest that the member's treatment plan includes a long-acting opioid when clinically appropriate (unless contraindicated).

Applies when total daily MME >50 mg.
Attestation must be documented in the medical record and included with the prior authorization request.

Conservative Treatment Requirements

Authorization Durations and Frequency Limits

short-acting and long-acting opioid prescriptions — Authorization will be for one year

Authorization duration for opioid prescriptionsAuthorization will be for one year

Applies toShort-acting and long-acting opioid prescriptions

Required supporting informationDocumentation of diagnosis, evaluation, medical assessment, risk assessment, signed pain management agreement, state controlled substance database check, and treatment plan

MME >120 mg/day prior authorization — 180 days

Duration for prior authorization when MME >120 mg/day180 days

Trigger for this authorization periodPrior authorization required for members taking >120 mg MME per day

Definitions

MME — Morphine Milligram Equivalent definition and role in policy

DefinitionMorphine Milligram Equivalent (MME): measure of opioid potency used to limit the combined total or MME

Role in policyMME is the metric that triggers prior authorization when daily MME exceeds 120 mg

PurposeUsed to assess combined opioid dose and determine medical necessity for exceeding standard limits

Background

This policy governs opioid prescribing safety controls for Blue Cross Blue Shield of Tennessee and sets prescriber attestations, required documentation, and monitoring steps that must be met before coverage is authorized. Key elements include: prescriber attestations regarding recent Medication-Assisted Treatment and recent co-prescriptions, completion of a risk assessment for aberrant opioid-related behavior, a signed pain management agreement within the prior 6 months, documentation of diagnosis and medical assessment, and a verified treatment plan between patient and provider.

The policy requires prescribers to check the state controlled substance database within the prior 90 days and, for members with elevated MME or certain risk histories, prescriptions should be written by or in consultation with a pain specialist or oncologist. Prior authorization is required for opioid regimens that exceed MME thresholds set by the policy.

Not Covered

Formulary limitation: Not all opioids may be covered on the member’s formulary. The policy explicitly notes that formulary coverage varies and coverage verification is required before assuming a specific opioid will be authorized.