Premera’s Opioid Safety Edits

  • January 17, 2019

    The Centers for Medicare and Medicaid Services (CMS) has taken a multilayered approach to the issue of misuse and abuse of opioids. CMS works closely with Part D plans to ensure safe and effective use of opioid medications while maintaining access to needed medications.

    Premera Blue Cross Medicare Advantage plans support CMS and has introduced additional pharmacy point of sale safety and quantity edits for opioids. These edits are medication safety checks that can be seen by the pharmacist when filling prescriptions and require the pharmacist document they have reviewed the identified safety concern with the prescriber directly. Prescribers may include relevant prescription information on the face of the prescription as appropriate to support this review.

    View the detailed information on all Premera Blue Cross opioid safety edits.

    Safety Edits Description Prescriber Action
    7-Day Supply Limit for Opioid-Naïve Members*

    *Members new to opioid therapy/no recent history of opioid use.    		 Prescriptions for opioid pain medications for greater than a 7-day supply in opioid naïve patients will reject for payment at the pharmacy. Prescribe a 7-day supply or less.

    If more than a 7-day supply is medically necessary, contact the dispensing pharmacy to obtain a plan override.

    Exemptions to a 7-day supply include active cancer related pain, end of life/palliative care.

    You can request prior authorization if the pharmacy can’t obtain an override. Call 844-449-4723.
    Opioid Care Coordination Safety Edit (OCC) Limits cumulative dosage to 90 morphine milligram equivalent (MME) per day and four or more prescribers and four or more pharmacies. Help ensure opioid prescribing is coordinated and limited to one prescriber/one medical health system when appropriate. Provide timely response to pharmacy outreach.
    Opioids Therapy started post Buprenorphine Initiation Alert for concurrent use of opioids and buprenorphine.

    Pharmacy may override the rejection with the prescriber’s approval.    		 Provide timely response to pharmacy outreach.
    Opioids and Benzodiazepines Alert for concurrent use of opioids and benzodiazepines.

    Pharmacy may override the rejection with the prescriber’s approval.    		 Provide timely response to pharmacy outreach.
    Duplicate Therapy – Long-Acting Opioids (LAOs) Alert for concurrent use of multiple LAOs.

    Pharmacy may override the rejection with the prescriber’s approval.    		 Provide timely response to pharmacy outreach.
    Drug Management Program Helps support safe use of prescription opioid medications, or other frequently abused medications.

    Identifies members who are prescribed opioids from several prescribers or pharmacies. If misuse or abuse is determined through provider discussion, the plan may limit how opioids are received.

    Limitations include: pharmacy lock-in, prescriber lock-in, or opioid restriction (limiting drug/quantity).    		 Engage with case management team in a timely manner.

    Consider a pharmacy/prescriber lock-in to better manage uncoordinated care.

    Active cancer, hospice, or members who reside in a long-term care setting may be excluded from opioid safety edits.

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