Durham, N.C. – Blue Cross and Blue Shield of North Carolina (Blue Cross NC) announced today that it was making three changes to its policies for opioid prescriptions and treatment for opioid dependency. The changes help address the state’s opioid epidemic and make treatment options more accessible for those with opioid dependency.
The three changes are:
- Limiting the first-time prescription of short-acting opioids to a seven-day maximum supply
- Requiring prior authorization before a member receives a first-time prescription for extended-release opioids
- Expanding coverage of treatments for opioid dependency to include a new drug called Sublocade
“Every day, opioid addiction destroys lives and tears apart families in North Carolina – and throughout our nation,” said Dr. Rahul Rajkumar, Senior Vice President and Chief Medical Officer at Blue Cross NC. “This is a national public health emergency. Everyone who is in a position to address this epidemic must do so. The policies we’re announcing today are the latest in a series of efforts from Blue Cross NC that will help prevent opioid addiction, treat opioid dependency, and save lives. You will see more from us.”
Details on the policy changes are as follows:
- Seven-Day Limit for First Fill of Short-Acting Opioids
Effective April 1, Blue Cross NC will limit the first-time prescription fill of short-acting opioids to a maximum of seven days. After the first prescription, customers will be able to fill future prescriptions for greater than a seven-day supply if it is clinically indicated and appropriate.
Nationally recognized Centers for Disease Control and Prevention guidelines on the appropriate use of opioids call for limiting the initial amount of drugs prescribed for acute pain. This lowers the risk of chronic opioid use and limits the amount of unused opioids that end up in the hands of people without a clinical need for prescribed pain relievers.
The NC STOP Act – signed into law in June 2017 – also puts a seven-day limit on first-time prescriptions of short-acting opioids.
Despite these clinical recommendations and new state laws, Blue Cross NC claims data show that roughly 15 percent of first-time acute opioid prescriptions exceed this maximum requirement. While this is down from 20 percent at the end of 2017, claims data shows that between 2,000 and 4,000 prescriptions are filled each month that exceed the seven-day limit.
The STOP Act limits first-time prescriptions for short-acting opioids and places new requirements on prescribers.
Under Blue Cross NC’s newly announced policy, any initial prescription for an immediate release opioid submitted at a pharmacy for more than seven days will be automatically rejected, and the pharmacy will be prompted to re-process the prescription for seven days or less. In the event this occurs, customers will not have to get a new prescription from their doctor unless it is for a controlled substance.
This change will impact commercial members with pharmacy benefit coverage through Blue Cross NC. It does not apply to members of the State Health Plan, Federal Employee Program, Medicare Part D members, or any self-funded employer groups that carve out pharmacy benefits to another pharmacy benefits manager.
- Prior Authorization for Extended Release Opioids
Effective April 1, providers will be required to obtain prior authorization from Blue Cross NC before prescribing extended release opioids to new patients.
Higher doses and longer duration of action increase the risk of overdose and death when extended release opioids are misused. CDC guidelines set an evidenced-based framework for how extended release opioids should be used in chronic pain management. Prior authorization will help ensure that framework is being followed.
In order to obtain authorization, providers must include:
- A documented formal evaluation for chronic pain with specific diagnosis.
- The documentation in the clinical record of a trial of immediate release opioids prior to starting extended-release products.
- A review of the state’s prescription drug monitoring program.
- Review and documentation of current medications to avoid dangerous or inappropriate combinations such as benzodiazepines.
Patients who are currently on extended release opioid therapy, including those being actively treated for cancer or who are hospice-eligible, will either be granted authorization through claims history or through their provider attesting to their current treatment.
As with the seven-day maximum change, this change will only impact commercial members with pharmacy benefit coverage through Blue Cross NC. It does not apply to members of the State Health Plan, Federal Employee Program, Medicare Part D members, or any self-funded employer groups that receive pharmacy benefits from another pharmacy benefits manager.
- Coverage of Sublocade for Opioid Dependency
Effective now, Blue Cross NC will cover Sublocade, an injectable drug designed to treat opioid dependency.
Successful treatment of opioid abuse disorder with Sublocade requires abstinence from opioids and related drugs of abuse such as Soma. A member with Blue Cross NC pharmacy benefits who is approved for Sublocade will not be able to fill a prescription for Soma or opioids at the pharmacy.
Providers will be required to get prior authorization for Sublocade.
The approval of Sublocade and subsequent block on Soma and opioid prescriptions lasts for 365 days. Providers must submit a request for the block to be removed.
This change will only impact commercial members with pharmacy benefit coverage through Blue Cross NC. It does not apply to members of the State Health Plan, Federal Employee Program, Medicare Part D members, or any self-funded employer groups that carve out pharmacy benefits to another pharmacy benefits manager.
Blue Cross NC’s three-pronged approach to addressing the opioid epidemic involves a focus on prevention, intervention and treatment.
Since 2013, the company’s efforts have lowered opioid prescriptions by 16 percent. These efforts include providing risk screening and education, contacting providers with significantly higher rates of opioids prescribing, monitoring for patients who “prescription shop,” and running a 24-hour member opioid help line.
Additionally, Blue Cross NC recently announced that the company would be investing $10 million dollars to address the opioid epidemic.