Medication Prior Authorization for Opioids
Customize your policy alerts
Sign up for all Highmark Blueshield Neny policy alerts
Know when Highmark Blueshield Neny releases new policies or updates existing guidance.
Monitor payer policy activity
Form and requirements for prior authorization of opioid medications for Highmark BlueShield members in North Carolina; governs what provider-completed documentation and clinical information are required to request authorization.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Authorization Criteria
Covered when ALL of the following are met:
If the provider selects None of the above on the clinical information section, the form indicates that the member does not have any of the documented indications that support opioid therapy (for example: chronic pain, cancer-related pain, end-of-life/palliative care pain, sickle cell pain, long-term care residency, documented acute pain where other agents would be insufficient, or pain related to a terminal illness). In that situation, clinical indications supporting opioid use are not documented on the form and authorization is not supported by the stated criteria.
Requests may be considered not medically necessary or may be denied when the submission lacks required clinical information. Examples include incomplete documentation answering whether the prescribed opioid amount is warranted for the member's clinical circumstances, absence of an ongoing monitoring plan for drug–drug interactions (for example with gabapentin, pregabalin, benzodiazepines, or sedative‑hypnotics), or missing medication history showing prior therapies tried and failed. The form also states that authorization does not guarantee payment.
Coding and Supply Options
| ICD-10 | Diagnosis and/or ICD-10 code(s) (exact codes to be provided by prescriber) |
Provider Actions and Submission Requirements
Submit prior authorization by fax or mail; one form per medication
Prior authorization requests must be submitted using the completed Medication Prior Authorization form. Fax the completed form and all clinical documentation to 1-866-240-8123 or mail the form to Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. Submit a separate form for each medication.
- Fax completed form and clinical documentation to 1-866-240-8123
- Or mail to Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
- Submit a separate form for each medication
Document evaluation of at least one conservative therapy
The form requires documentation that at least one conservative therapy was evaluated prior to opioid authorization, including non-opioid medications (NSAIDs, acetaminophen, TCAs, SNRIs, anticonvulsants), exercise/physical therapy, weight loss, or cognitive behavioral therapy.
- Non-opioid medications (e.g., NSAIDs, acetaminophen, tricyclic antidepressants, SNRIs, anticonvulsants) evaluated
- Exercise therapy or physical therapy evaluated
- Weight loss or cognitive behavioral therapy evaluated
Complete all required form fields and include supporting clinical documentation
Providers must complete all required patient and provider fields on the form, including medication name, strength, requested quantity, requested supply day (30 days, 90 days, or other), directions, and diagnosis with ICD-10 code(s); include clinical information such as pain type, prior therapies tried/failed, PDMP check, monitoring plan, hospice status if applicable, and the prescribing physician’s signature and date.
- Medication information: name, strength, requested quantity, requested supply day (30 days, 90 days, or other), directions
- Diagnosis and/or ICD-10 code(s)
- Clinical information: pain type/indication, prior therapies attempted, PDMP check, monitoring plan for drug-drug interactions, hospice status if applicable
- Provider information: physician name, NPI, contact info, physician signature and date
- Include supporting clinical documentation when faxing or mailing
Incomplete or inaccurate information may lead to denial; authorization not a payment guarantee
Incomplete, inaccurate, or missing information on the form may result in denial of the request; authorization, if granted, does not guarantee payment and payment is subject to member eligibility.
- Ensure all information is true, accurate, and complete to avoid denial
- Authorization does not guarantee payment; payment remains subject to member eligibility
Conservative Treatment Requirements
Conservative Therapy Evaluation
At least one of the following conservative therapies must be indicated on the form:
Provider must indicate evaluation on the form.
Definitions and Monitoring Considerations
Background
This prior‑authorization form is used to document the clinical rationale and safety steps when requesting opioid therapy for members. It supports opioid use for a range of situations including chronic pain, pain associated with cancer, end‑of‑life or palliative care pain, sickle cell pain, members who reside in long‑term care facilities, documented acute pain where other agents would be insufficient, and pain related to a terminal illness. The form captures severity (need for daily, around‑the‑clock, long‑term opioid treatment), prior conservative therapies evaluated, PDMP review, patient/guardian education, and other monitoring and safety considerations required for authorization.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.