Capital BlueCross Update: Opioid Prescription Policy

The opioid addiction epidemic is one of America’s foremost health crises. According to the most recent statistics from the Centers for Disease Control and Prevention (CDC), opioids kill more than 33,000 people annually, and opioid abuse/overdose is considered a leading cause of shortened life expectancy in the U.S.

The nation’s opioid epidemic reflects a complex set of circumstances. The pattern of opioid prescription—including dose and duration—and risk factors of age, gender, and condition are major determinants of whether a patient becomes dependent.

In response to this growing crisis, Capital BlueCross has developed a comprehensive strategy to ensure safer drug use in our network including changes to our prescription drug formulary. We continue to notify all impacted members of the modified commercial (not Medicare) formulary changes:

Opioid prescriptions have new quantity level limits (QLLs) and daily dosage limits.
These limits are in effect for off-exchange members and will apply to exchange members effective January 1, 2018.
Prior authorization for long-acting or extended release opioid preparations is required.
Prescriber justification for non-cancer and non-terminal conditions will be reviewed to assess medical necessity.
Prior authorization is now required for oral fentanyl, methadone, and medication-assisted treatments (MATs)—namely Suboxone, Bunavail, Zubsolv, buprenorphine, buprenorphine/naloxone, and immediate-release sublingual or mucosal absorption preparations.

Opioid Prescription FAQs

  1. Can a member get additional quantities of medication above the new limits to reflect the original prescription?  Possibly, when the member’s doctor completes a QLL review.  If approved, the approval for the additional number of medications will be input into CVS’ Caremark Pharmacy system to allow the pharmacy to fill the extra supply.
  2. Can a member and/or provider appeal to allow up to the original quantity of medication on his or her prescription?  Yes, the member has appeal rights. Proper appeal documentation, medical records, and/or letters of medical necessity and diagnosis can be sent to our pharmacy appeals area. Note: There are no guarantees of the outcome of the appeal; however, the pharmacy appeals department will mail the letter to the member and if necessary, contact the member for further explanation.
  3. Was this formulary change a Capital BlueCross decision or a federal- or state- imposed change?  The over-utilization of opioids and associated deaths have reached epidemic proportions. As a result, federal, state, and local authorities have partnered to ensure judicious use and monitoring of these medication quantities. As part of this initiative, payer organizations like Capital BlueCross are able to utilize data that will identify potentially harmful doses and quantities which warrant further review by a qualified health care professional.
  4. May a member purchase medication outside of the insurance restrictions?  Yes, a member with a valid prescription from his or her doctor can fill all or the remainder of his or her prescription outside of the insurance quantity limits.
  5. If a member purchases medication outside the limits of the insurance restrictions, can he or she file a paper claim for reimbursement?  1) If the script was outright filled outside the insurance restriction, then a member can file a paper claim; however, the only level of reimbursement will be up to the new restricted limit. 2) If the member fills the script for the new quantity level and his or her doctor does a QLL for an additional amount, then any amount prescribed over the new limits will not be eligible for reimbursement because the maximum benefit limit has already been obtained.


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The information provided is for informational purposes only and does not constitute legal advice. The information above contains only a summary of the applicable legal provisions and does not purport to cover every aspect of any particular law, regulation or requirement. Depending on the specific facts of any situation, there may be additional or different requirements. This is to be used only as a guide and not as a definitive description of your compliance obligations.