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:

Inappropriate Drug Therapy Combinations
The pharmacy may need to contact your prescriber to resolve these issues:

  • Opioids & Medication Assisted Treatment (MAT): reject for an opioid claim secondary to a MAT drug (includes only buprenorphine-combination products)
  • Opioids & Benzodiazepine: reject for an opioid drug if the member has an existing claim for a benzodiazepine and vice versa
  • Opioids & Prenatal Vitamin: reject for an opioid drug if the member has an existing claim for a prenatal vitamin claim and vice versa

Inappropriate opioid quantities or dosing
The pharmacy may need to contact your prescriber to resolve these issues:

  • Members already on opioids: reject for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >90 MME*/day
  • Members new to opioids: reject for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >50 MME*/day
  • Members new to opioids: reject for Short Acting Opioid prescriptions for >7 day supply
  • Members new to opioids: reject for a Long Acting Opioid with no paid claim for a Short Acting Opioid

The following requires prior authorization from your prescriber:

  • Members already on opioids: Prior Authorization required for a cumulative Short Acting Opioid/Long Acting Opioid dose check for >180 MME*/day

Therapeutic Dose Limit
The pharmacy may need to contact your prescriber to resolve this issue:

  • Cumulative acetaminophen dose check (with opioid-containing drugs) >4 grams/day (reject)

Refill Threshold

  • This edit narrows the refill window for Schedule II-V controlled drugs to a 90% threshold at retail pharmacy and 80% at mail order.

Opioid Management Edits
The following require prior authorization from your prescriber if exceeding the limit:

  • Members new to opioids: Short Acting Opioids maximum 50 MME*/day
  • Members new to opioids: Short Acting Opioids 7 days supply limit
  • Members already on opioids: Short Acting Opioids maximum 90 MME*/day. 
  • All members: use of Short Acting Opioids required before Long Acting Opioids
  • All members: Quantity Limits on all Long Acting Opioids based on FDA maximum dosing frequency (i.e. once daily)
  • All members: Maximum 2 opioid fills within a 60-day time period

Pediatric (<19 years of age) Edits 
The following require prior authorization from your prescriber if exceeding the limit:

  • All pediatric members: PA required for all opioid containing cough and cold medications
  • Pediatric members new to opioids: 3 days supply limit

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 authorizations

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. 

Opioids FAQs

This type of medication is generally used for the treatment of pain.

Is it safe to take opioid medications?
Opioid medications can be used to help with short- and long-term pain. However, extended use of opioids can cause serious risks that you and your doctor should discuss and monitor closely. It is very important that you understand why you are being prescribed opioid(s).

What are the risks of taking opioids for a long time?

  • Tolerance – Over time, you may need higher doses to relieve your pain.
  • Dependence – You may have withdrawal symptoms when you stop taking opioids. This can happen after taking them for less than a week.
  • Addiction – You may not be able to control your opioid use.
  • Overdose or death

How do I safely take opioid medications?

  • Always follow your doctor’s directions and never share your medications with others.
  • Don’t take your medication more often than prescribed. Talk to your doctor or pharmacist before you take any extra doses.
  • Stay away from dangerous drug interactions. Talk to your doctor or pharmacist about all the drugs you take. Mixing opioids with any of the following can greatly add to the risk of overdose:
    • alcohol
    • sleeping pills (such as zolpidem (Ambien®) or zaleplon (Sonata®))
    • anxiety drugs (such as diazepam (Valium®), alprazolam (Xanax®), and lorazepam (Ativan®))
  • If your pain is under control, ask your doctor if you should take them less often or change to other pain relief options.
  • Keep your opioid medications in their original package and with the original labels. Store them in a place that is out of reach of children and can’t be easily accessed by others (locked cabinet).
  • For safety reasons, unused medications should be disposed of as soon as possible. Talk to your pharmacist for safe drug disposal options in your area.

What alternative pain management options should I consider?
Talk to your doctor about ways to manage your pain that do not involve prescription opioids. Some of these options may work better and have fewer risks and side effects. Depending on the type of pain you are experiencing, options may include:

  • Over-the-counter medications such as ibuprofen (Motrin®), acetaminophen (Tylenol®) or naproxen (Aleve®).
  • Prescription-strength anti-inflammatory medications such as celecoxib (Celebrex®), diclofenac (Voltaren®), and etodolac (Lodine®).
  • Some prescription non-opioid medications that target pain-producing nerves, such as gabapentin (Neurontin®) and pregabalin (Lyrica®).
  • Injectable and topical therapies.
  • Chiropractor services, physical and other therapies, heat or cold compresses, exercise, acupuncture and cognitive behavioral therapy.

What is naloxone and is it safe to use?
Opioids can sometimes slow or even stop your breathing. This can happen if your body can’t handle the amount of opioids that you take that day. Naloxone is a medication that can undo the effect of opioids in your body. Naloxone is safe and can save your life. Talk to your doctor or pharmacist to see if it should be prescribed to you and how to use it correctly. In some states, naloxone can be purchased in the pharmacy without a prescription from a physician.

What opioid treatment services are available?
For information on your plan’s benefits related to treatment for prescription drug abuse, including medication assisted treatment, mental health and counseling services, call Customer Service at the phone number on the back of your ID card.

*Morphine Milligram Equivalents are a way to compare different opioid medications based on their strength as compared to morphine