New opioid management program for Commercial, Medicaid, and Exchange plans 

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.  Effective February 1, 2018, we will implement our standard opioid management program which will be aligned with the "Guideline for Prescribing Opioids for Chronic Pain" issued by the Centers for Disease Control and Prevention (CDC) in March 2016.

This program does NOT include Medicare plans.

The enhanced programs will: 

  • Limit days supply
    The length of the first fill (when appropriate) will be limited to seven days 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 (PA) request if it is important to exceed the seven-day limit.
  • Limit quantity of opioids
    The quantity of opioid products prescribed (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 unless minimum FDA-labeled strength/dose/frequency exceeds 200 MME per day. Quantities higher than that would require an appeal. 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 moving to an extended-release (ER) formulation, unless the member has a previous claim for an IR or ER product, or the prescriber submits a PA.