Blue Review
A newsletter for physician, professional, facility, ancillary and Medicaid providers

September 2018

Appropriate Use of Opioids Program Launched Aug. 1, 2018

On Aug. 1, 2018, Blue Cross and Blue Shield of Texas (BCBSTX) implemented the new Appropriate Use of Opioids Program. This program was developed to encourage the appropriate use of prescription opioids and advocate patient safety for our members. Elements in the new program follow safety guidelines as recommended by the Centers for Disease Control and Prevention (CDC) and other nationally recognized guidelines.

The Appropriate Use of Opioids Program elements include:

  • Opioid Immediate Release (IR) Duration Limit
    Limits an initial IR prescription opioid fill for up to a seven-day supply for an opioid naïve patient. A member is considered “opioid naïve” if he or she has not had an opioid prescription filled within the past 60 days. Once the initial seven-day supply has been filled, subsequent fills will not be subject to the seven-day duration requirement as long as the member is not opioid naïve.
  • Morphine Equivalent Dose Concurrent Drug Utilization Review (MED cDUR) Hard Edit
    Promotes the lowest effective dosage of opioids by monitoring and limiting the cumulative daily Morphine Equivalent Dose (MED) to no more than 200 mg per day. The MED is calculated across the submitted claim and selected historical claims. This point-of-sale edit denies claims when total MED is greater than or equal to 200 mg per day for seven consecutive days.
  • Opioid Quantity Limits
    Continues to apply existing opioid dispensing limits/quantity limits to single-entity, extended-release and some IR opioids consistent with FDA-recommended dosage guidelines. Dispensing limits are published on the bcbstx.com website and updated quarterly.

Please note: The Appropriate Use of Opioids Program was implemented based on the member’s benefit. Most members with BCBSTX prescription drug coverage may be subject to the criteria threshold limits established within this program regardless of their plan renewal date. This program will not apply to members with Medicare Part D or Medicaid coverage. Please call the number on the member’s identification card to verify coverage, or for further assistance or clarification on your patient’s benefits.

If you have a patient who requires a prescription order for an opioid that exceeds the established limits of this program, you may submit an authorization request to BCBSTX for coverage consideration. Prior Authorization and Step Therapy Programs fax forms can be found in the Pharmacy section of the BCBSTX website.

There may be future drug list changes in the opioid drug category. These updates can be found in this newsletter, as well as the News and Updates and Pharmacy Program sections on the BCBSTX provider website.

This information is for informational purposes only and is not intended to replace your clinical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage. Only you, in direct consultation with your patient, can determine your patient’s drug therapy, regardless of the member’s benefits.