CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Opioid Prescribing and Prior Authorization Criteria

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Defines prior authorization, prescribing restrictions, and coverage criteria for long-acting and short-acting opioids and MME limits for Blue Cross Blue Shield - Tennessee members.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyOpioid Prescribing and Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit required documentation including diagnosis, risk assessment, signed pain management agreement, and state controlled substance database check when requesting long‑acting or extended short‑acting opioid therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 mg/dayMME threshold requiring prior authorization

90 mg/dayPrescriber restriction MME level

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CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Opioid Prescribing and Prior Authorization Criteria

Customize your policy alerts

Sign up for all blue cross blue shield - tennessee policy alerts

Know when blue cross blue shield - tennessee releases new policies or updates existing guidance.

Monitor payer policy activity

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Defines prior authorization, prescribing restrictions, and coverage criteria for long-acting and short-acting opioids and MME limits for Blue Cross Blue Shield - Tennessee members.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyOpioid Prescribing and Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 mg/dayMME threshold requiring prior authorization

90 mg/dayPrescriber restriction MME level

Default short‑acting limit

1 yearAuthorization duration

180 daysMME exceedance coverage duration

Coverage Criteria for Opioids

inv-01: Long-acting Opioids - Covered when ALL of the following are met

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

Long-acting opioid criteria: a. Prescriber attests that the patient HAS NOT received Medication-Assisted Treatment for the treatment of opioid dependence in the last 60 days AND b. Prescriber attests that the patient HAS NOT received a prescription for an opioid, a benzodiazepine AND a muscle relaxant in the last 60 days AND c. Documentation that shows the patient's diagnosis, evaluation and medical assessment for the requested medication AND d. Prescriber has completed a risk assessment for aberrant behavior associated with opioid misuse AND e. A signed pain management agreement between the patient and prescriber in the past 6 months AND f. Prescriber has checked the state controlled substance database in the last 90 days AND g. A treatment plan is in place between the patient and provider AND h. Previous treatment with short-acting opioids at the lowest possible dose.

All items required

inv-02: Short-acting Opioids - Covered when ONE of the following is met

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

Short-acting exceptions: a. Patient had surgery in the last 14 days OR b. Patient has suffered a severe burn or major physical trauma in the last 30 days OR c. Patient is currently in a licensed health care facility OR d. Patient is being seen by a pain management specialist or supervisee of a pain specialist OR e. Patient has been treated with an opioid for greater than 90 days in the last year.

Any single condition suffices

inv-03: Short-acting Opioids - Additional ALL criteria for authorization

Short-acting opioids will be approved when ALL of the following are met (in addition to meeting exception above for >7 days):

Short-acting baseline criteria: a. Prescriber attests that the patient HAS NOT received Medication-Assisted Treatment for the treatment of opioid dependence in the last 60 days AND b. Prescriber attests that the patient HAS NOT received a prescription for an opioid, a benzodiazepine, AND a muscle relaxant in the last 60 days AND 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 AND d. Documentation that shows the patient's diagnosis, evaluation, and medical assessment for the requested medication AND e. Prescriber has completed a risk assessment for aberrant behavior associated with opioid misuse AND f. A signed pain management agreement between the patient and prescriber in the past 6 months AND g. Prescriber has checked the state controlled substance database in the last 90 days AND h. A treatment plan is in place between the patient and provider.

All items required

The policy does not list any exclusion criteria for long-acting or short-acting opioids; across the opioid sections the document explicitly notes Exclusion Criteria = N/A. Where prior authorization and required documentation are described, no separate exclusions are specified in the source text.

Providers should therefore assume decisions are made by applying the stated coverage criteria, documentation requirements, MME thresholds, and prescriber restrictions rather than by any additional exclusion conditions.

MME Thresholds and Related Coding

inv-05: MME prior authorization threshold

MME prior authorization threshold> 120 mg/day

Prior authorization coverage duration when >120 mg/day180 days

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

inv-06: Short-acting opioid treatment plan threshold for including long-acting opioid

Short-acting to long-acting treatment-plan threshold> 50 mg/day — prescriber must attest treatment plan includes a long-acting opioid unless contraindicated

Applies to authorization of >7 day short-acting supplyRequired as part of the ALL criteria in addition to meeting an exception for >7 days

Provider Actions, Authorization, and Documentation Requirements

Prior Authorization

Long-acting opioids require prior authorization

Prior authorization is required for long-acting opioids; approvals are granted for one year when all specified criteria are met, including documentation, risk assessment, signed pain management agreement, state PDMP check within 90 days, treatment plan, and prior short-acting opioid trial at lowest dose.

Authorization duration: one year
All long-acting criteria (a–h) must be met prior to approval

Prior Authorization

Short-acting opioids >7 days require prior authorization

Prior authorization is required for short-acting opioid supplies greater than the initial seven-day limit; approvals are granted for one year when the listed exception (one of a–e) is met plus the additional required documentation and agreements.

Initial limit: seven-day supply; >7 days requires meeting one exception from chunk 1
Authorization duration: one year when all short-acting criteria are met

Conservative Treatment and Prior Therapies

Supply Limits and Frequency Rules

inv-19: Short-acting opioid supply — initial seven-day supply default

Initial short-acting opioid supply default7 days (initial seven-day supply)

Coverage duration for initial seven-day limit detailsCoverage duration: 30 Days* (per chunk)

Exceptions allow >7 daysGreater than seven-day supply approved if ONE qualifying condition is met (surgery within 14 days, severe burn/major trauma within 30 days, currently in licensed facility, being seen by a pain specialist/supervisee, or treated with opioid >90 days in last year)

Definitions and Terms

inv-17: Morphine Milligram Equivalent (MME)

Definition of MMEMorphine Milligram Equivalent (MME): a measure of opioid potency used to compare strength of different opioids to morphine

Policy use of MMEPolicy uses MME thresholds to determine prior authorization requirements (see >120 mg/day, >90 mg/day, >50 mg/day)

Actionable MME threshold requiring prior authorization> 120 mg/day triggers prior authorization requirement

Background

This policy defines prior authorization requirements, prescribing restrictions, and documentation standards for outpatient opioid therapy for Blue Cross Blue Shield of Tennessee members. It distinguishes coverage rules for long-acting opioids and short-acting opioids, sets MME-based thresholds that trigger prior authorization, and specifies provider actions and monitoring expectations.

Key operational points: prior authorization is required for long-acting opioids with approvals issued for one year when all listed criteria are met; short-acting opioids default to an initial seven-day supply with extensions beyond seven days allowed only when specified exceptions apply (e.g., recent surgery, major trauma, care in a licensed facility, treatment by a pain specialist, or opioid use >90 days in the last year); and prior authorization is required for members receiving > 120 mg/day MME (authorization duration 180 days).

Providers must supply clinical documentation demonstrating diagnosis, nature and intensity of pain, past and current treatments, a treatment plan, evidence of risk assessment and a signed pain management agreement within the past 6 months, and verification of a state controlled substance database check within the last 90 days. When a prescriber attests the member has an elevated MME > 90 mg/day or a history of substance use disorder, prescriptions should be written by or in consultation with a pain specialist or oncologist.

Imaging Requirements

Note

Imaging requirements

No imaging requirements are specified in the policy.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyOpioid Prescribing and Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Documentation contextMust be attested by prescriber and documented among other required elements (diagnosis, evaluation, risk assessment, pain agreement, PDMP check, treatment plan)

inv-07: Prescriber-attested elevated MME threshold for specialist consultation

Prescriber-attested elevated MME threshold for specialist consultation> 90 mg/day — prescribed by or in consultation with a pain specialist or oncologist when prescriber attests MME > 90 mg/day and/or history of substance abuse disorder

Applies to long-acting and short-acting opioidsPolicy indicates this prescriber restriction under both Long-Acting and Short-Acting opioid sections

Includes substance abuse history conditionAlso applies when there is a history of substance abuse disorder (including alcohol)

Prior Authorization

MME >120 mg/day requires prior authorization

Prior authorization is required for members taking greater than 120 mg MME per day; when authorized under this threshold the coverage duration is 180 days.

MME threshold triggering prior authorization: >120 mg/day
Coverage duration when authorized: 180 days

Step Therapy

Prescriber attestation for transition to long-acting opioid at >50 mg MME/day

When short-acting opioid dosing exceeds 50 mg MME/day, the prescriber must attest that the member's treatment plan includes a long-acting opioid unless contraindicated as part of the authorization criteria.

Attestation required when MME >50 mg/day that treatment plan includes long-acting opioid unless contraindicated

Documentation Required

Required clinical documentation for any opioid authorization

Submit documentation showing diagnosis, evaluation and medical assessment, nature and intensity of pain, past and current treatments, underlying/co-occurring conditions, medical necessity to exceed MME limits, and an active treatment plan to support authorization.

Diagnosis, evaluation and medical assessment
Nature and intensity of pain; past and current treatments
Medical necessity to exceed standard MME limits
Treatment plan between patient and provider

Documentation Required

Risk assessment and monitoring documentation required

Provide a signed pain management agreement within the past 6 months, a completed risk assessment for aberrant behavior, and evidence that the prescriber checked the state controlled substance database within the last 90 days as part of risk/monitoring documentation.

Signed pain management agreement within past 6 months
Risk assessment for aberrant behavior associated with opioid misuse
State controlled substance database (PDMP) check within last 90 days

Denial Risk

Documentation-based denials possible

Failure to provide required documentation—including diagnosis/evaluation/medical assessment, signed pain management agreement within 6 months, recent PDMP check (within 90 days), or risk assessment—may result in denial of long-acting or short-acting opioid authorization.

Missing documentation of diagnosis, evaluation, or medical assessment
No signed pain management agreement within past 6 months
No PDMP check within last 90 days
No documented risk assessment for aberrant behavior

Denial Risk

Denial risk when MME exceeds 120 mg/day without authorization

Use of opioids at a combined total greater than 120 mg MME/day without prior authorization will trigger the prior authorization requirement and may result in denial if criteria and required documentation are not met.

Threshold for denial risk: >120 mg MME/day without prior authorization