HealthCare News

New Drug-Related Prior Approval with Quantity Limit Criteria for Opioid Extended-Release and Immediate-Release

Issue: #409 Jul2019

Topic: Education


Opioid Extended Release Prior Approvals and Quantity Limits
Patients that are currently on an extended-release opioid as of 7/1/19 will be allowed continuation of therapy for the same agent. Quantity limits (QLs) are currently in place for all extended-release opioid products.

Requests for opioid ER agents, including quantities above the allowed limit, will be reviewed when patient-specific documentation has been provided.

Opioid Immediate Release Prior Approvals and Quantity Limits
Patients that are currently on an immediate-release opioid as of 7/1/19 will be allowed continuation of therapy for the same agent. In addition, patients new to therapy receiving a prescription of ≤7 days of therapy and < 50 MME per day will not require a prior approval.

The program will allow for uses beyond these limits if the patient has a diagnosis of cancer pain due to an active malignancy, is eligible for hospice care, or has provided documentation showing use beyond these limits is appropriate.

Products impacted
These PA programs apply to Commercial and Health Insurance Marketplace lines of business.

New PA criteria can be accessed at www.myprime.com > Forms > Prior Authorization.

Questions?
If you have questions, please contact BCBSND Provider Services at 800-368-2312.