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Appropriate Use of Opioids Program Launched August 1, 2018

Posted August 8, 2018

On Aug. 1, 2018, Blue Cross and Blue Shield of Illinois (BCBSIL) 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 immediate release (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 (ER) and some IR opioids consistent with U.S. Food and Drug Administration (FDA) recommended dosage guidelines. Dispensing limits are published on the bcbsil.com website and updated quarterly.

Please note: The Appropriate Use of Opioids Program was implemented based on the member’s benefit. Most members with BCBSIL prescription drug coverage may be subject to the criteria threshold limits established within this program, regardless of the member’s 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 ID card to verify coverage, or for further assistance or clarification on your patient’s benefits.

If your patient requires a prescription order for an opioid that exceeds the established limits of this program, you may submit an authorization request to BCBSIL for coverage consideration on behalf of your patient. You can find the fax forms on the Prior Authorization and Step Therapy Program webpage.

There may be future drug list changes in the opioid drug category. Please refer to News and Updates, the Blue Review provider newsletter and Pharmacy Program section for any future opioid updates that may be applicable to your patient(s).

* Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep 2016; 65 (No. RR-1): 1-49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

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.