Opioid management program for commercial members

Opioid painkillers provide needed relief to those with acute or chronic pain. But given their potential for harm, and the very real–and pervasive–problem of misuse and abuse, ensuring appropriate use is more critical now than ever before. Our standard opioid management program is aligned with the “Guideline for Prescribing Opioids for Chronic Pain” issued by the Centers of Disease and Prevention (CDC) in March 2016 and contains the following features:

  • Limit days’ supply
    Coverage for the length of the first fill (when appropriate) will be limited to three days for members 19 and under or 7 days for members over 19 years of age for immediate release, new acute prescriptions for plan members who do not have a history of prior opioid use, based on their prescription claims. A physician can submit a prior authorization request if requesting  to exceed the seven-day limit.
  • Limit quantity of opioids
    The quantity of opioid products covered (including those that are combined with acetaminophen, ibuprofen or aspirin) will be limited up to 90 Morphine Milligram Equivalent (MME) per day (based on a 30-day supply). Prescribers who believe their patient should exceed CDC Guideline recommendations can submit a PA request for up to 200 MME per day. Requests for coverage of quantities over 200 MME per day will require an appeal. Coverage for opioid products containing acetaminophen, aspirin, or ibuprofen will be limited to 4 grams of acetaminophen or aspirin, and 3.2 grams of ibuprofen per day.
  • Require step therapy
    Use of an immediate-release (IR) formulation will be required before approving coverage of an extended-release (ER) formulation, unless the member has a previous claim for an IR or ER product, or the prescriber submits a PA.

If you fill a prescription for an opioid (a covered drug that is a narcotic substance contained in U.S. Drug Enforcement Administration Schedule II), you may choose to obtain a fill in a lesser quantity than the full amount prescribed.  If you do, you may then choose to later obtain the remainder of the prescribed fill.  You will not be responsible for any copayment amount beyond the amount that would normally apply if you obtained the entire fill at once.

Pain management alternatives to opioid products

If you are interested in pain management alternatives to opioid products, speak to your provider. Many non-opioid medications and treatments are available. These include, but are not limited to, those listed below.

Non-opiate medication treatment options:

  • Ibuprofen
  • Topical Lidocaine (Note: some lidocaine products require prior authorization)

See our formulary for further information about our prescription drug formulary and prior authorization requirements. 

Non-medication treatment modalities:

  • Chiropractic care
  • Physical therapy services
  • Behavioral health providers with pain management-related specialties, such as cognitive behavioral therapy, pain management and treatment of chronic pain.  For assistance in finding a behavioral health provider, call 1-888-421-8861 (TDD/TTY: 1-781-994-7660).

These services may require prior authorization or may be subject to benefit limitations; see your Member Handbook/Evidence of Coverage and Schedule of Benefits for further information about how your plan covers these services.  

Additional medications and treatments are available which may also serve as pain management alternatives to opioid products. These include other medications, certain other types of therapies, treatment by certain types of non-behavioral health specialists, certain types of surgery, and certain types of injections.