Elite Opioid drug list update
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Pharmacy policy listing opioid and opioid-combination products with specified quantity limits for adult and pediatric (3-day) supply; applies to members whose benefits include pharmacy coverage under Capital BlueCross plans.
No material clinical or coverage changes in this revision.
Coverage Criteria
The listing in this pharmacy policy is informational and does not itself guarantee coverage. Coverage is determined by the member's individual or group contract language; members’ benefits govern which pharmaceuticals are covered, excluded, subject to limits, or require authorization. Providers and members should consult the applicable benefit information or contact Capital BlueCross for definitive coverage decisions.
Provider Actions & Verification
Quantity Limits and Prior Authorization
Quantity limits are applied to many opioid analgesic formulations. Adult and pediatric (3-day) limits are specified per product and may restrict dispensed volume or tablet counts. If a member's benefit requires prior authorization for quantities exceeding these limits, obtain authorization before dispensing.
- Limits vary by NDC/formulation and strength — consult pharmacy system for product-specific maximums
- Pediatric limits are commonly expressed as a 3-day supply (e.g., 270 mL or 18 tablets depending on product)
- Where the member's benefit requires authorization for quantities above the limit, prior authorization must be obtained
Provider Actions
Providers should take these steps when prescribing/dispensing medications subject to this policy: verify product-specific quantity limits in the pharmacy or benefit system; confirm whether prior authorization or step therapy applies; provide clinical documentation when requesting authorization; and contact Capital BlueCross Provider Services for clarifications or to initiate an authorization request.
- Verify the member's benefit and prescription-specific quantity limits prior to dispensing
- If prescribing quantities that exceed published limits, submit a prior authorization request with supporting clinical rationale
- Document indication, dose, planned duration, and any prior therapies when submitting authorization requests
- For urgent prescribing needs, contact Capital BlueCross as directed in the provider portal or on the member's ID card
Benefit Determination Caveat
Benefit determinations must be made using the member's contract language. The presence of this pharmacy policy does not guarantee that a drug is a covered benefit for a specific member. Providers and members should consult the member's benefit information or contact Capital BlueCross to confirm coverage, exclusions, limits, and any authorization requirements.
- This policy may list standard quantity limits but does not replace the member's contract or plan documents
- Coverage, exclusions, and required authorizations depend on the member's specific plan and contract language
- When in doubt, confirm coverage and benefit limits through the provider portal or Capital BlueCross Customer/Provider Services
Benefit Verification
Providers and members should verify benefits directly with Capital BlueCross prior to initiating therapy. The lists and limits in this policy may not reflect a member's coverage, prior authorizations, or plan-specific restrictions.
- Check eligibility and pharmacy benefits in the provider portal or via payer phone support
- Do not assume a drug is covered or that the quantity limit matches the member's plan without verification
- Confirm prior authorization requirements and obtain necessary approvals before dispensing quantities above the plan limit
Quantity Limits for Listed Opioids
Naming Conventions & Definitions
Background
This document is a formulary/list update specifying opioid analgesic products and associated quantity limits. It clarifies the naming convention used in the list: UPPERCASE names = Brand and lowercase names = Generic. The policy provides quantity limits per product (adult and pediatric 3-day limits where specified) but does not replace benefit verification; consult the member's contract or Capital BlueCross for benefit applicability and any authorization requirements.
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