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Attention ICP and FHP Providers: Prior Benefit Authorizations for Opiate Claims

Posted December 14, 2015

Effective Dec. 1, 2015, for Blue Cross Community ICPSM, or Integrated Health Plan, and Blue Cross Family Health PlanSM (FHP) members, a prior benefit authorization is required for prescriptions of opiates when the opiate is used within 30 days of a buprenorphine-containing product. The ICP or FHP member must meet prior benefit authorization criteria before the opiate claim may be paid. 

The Blue Cross and Blue Shield of Illinois (BCBSIL) prior authorization program helps promote the appropriate use of an opioid concomitantly with a buprenorphine product when the opioid is being requested for anticipated acute pain (e.g., surgical pain) or unanticipated acute pain (e.g., trauma). The prior authorization program will also support a quantity limit for those agents that currently have a quantity limit through the Pain Quantity Limit program. Additionally, the prior authorization program allows for a one-time fill of short-acting requests where the prescriber has submitted documentation explaining the need for the requested agent. 

Benefit prior authorization requests may be submitted online via the CoverMyMeds® site at covermymeds.com. Additional information on CoverMyMeds is available in our Provider Tools section. A link to CoverMyMeds also is available to registered users on the AvailityTM Web Portal, under the Authorizations menu. While electronic options are preferred, benefit prior authorization requests also may be called in to 800-285-9426, followed by a statement with supporting documentation, which may be faxed to 877-243-6930, or mailed. 

Please note that the fact that a service has been preauthorized/pre-certified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. 

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible for its products and services. Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions regarding the products or services they offer, you should contact the vendor(s) directly. 

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.