Blue Cross Community Health PlansSM (BCCHPSM): New Program Notification: Opioid Diagnosis Code Required at Pharmacy

Posted October 23, 2019

The purpose of this update is to notify Blue Cross and Blue Shield of Illinois (BCBSIL) independently contracted providers about a new program that will continue our efforts to prevent diversion and inappropriate use of opioids while still providing access for medically necessary purposes. 

To further ensure proper utilization of opioids we have worked closely with our Pharmacy Benefit Manager (PBM), Prime Therapeutics, to build and implement a Diagnosis (Dx) code requirement at the dispensing pharmacy, which may improve care and disease management engagement with our members. This new process helps to ensure that opioid prescriptions covered for our members are appropriate and the dispensing pharmacists are aware of the member’s pain treatment needs.    

Effective Nov. 1, 2019:  BCBSIL will require each opioid prescription to have a valid and appropriate diagnosis code (defined below). Excluded from this requirement, will be buprenorphine products used for treating opioid addiction.

  • Valid Code: Current ICD-10 Dx codes can be found in the Centers for Medicare & Medicaid Services (CMS) coding database:
  • Appropriate Code: A valid ICD-10 Dx code that is an appropriate indication for the use of opioids (i.e. G89.3 Neoplasm related pain).

As a reminder if you are a provider that is a Part 2 Program under the Substance Abuse and Mental Health Services Administration (“SAMHSA”) 42 CFR Part 2 Rules (the “Rules”) you may have obligations to obtain a patient consent and provide notices related to the use or redisclosure of the diagnosis information to the dispensing pharmacy.

For questions about drug coverage, plan members can call the Customer Service number on their member ID card.

If you have any questions regarding processing claims, please call the Prime Contact Center at 800-821-4795.

Prime Therapeutics LLC (Prime) is a separate pharmacy benefit management company contracted by BCBSIL to provide pharmacy benefit management and other related services. BCBSIL, as well as several Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

Blue Cross Community Health Plans is provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association.