December 20, 2023
Lee Podley
Clinical Pharmacist
This update applies to Blue Cross and Blue Shield of Montana (BCBSMT) group and Individual & Family Market members with Prime Therapeutics as their pharmacy benefit manager.
What’s new:
The Appropriate Use of Opioids (AUO) program will be retired effective January 1, 2024. However, BCBSMT will continue to promote safe and effective use of prescription opioids through an approach that more closely aligns with the Center for Disease Control’s 2022 Guidelines for Prescribing Opioids for Pain, which emphasize flexibility and individualized care.
New Approach:
BCBSMT’s new approach will eliminate hard edits – or benefit rejections at the pharmacy counter – and instead be updated to soft edits, which will allow the pharmacy or provider to determine whether to dispense.
- The soft edits are in place to alert the pharmacy if: an opioid naïve member has an opioid prescription that exceeds seven days; or, if a member has exceeded dosage limits and has filled overlapping opioid prescriptions at two or more pharmacies and from two or more providers.
- A member is considered opioid naïve if they do not have opioid prescription within the past 60 days, based on pharmacy claims data. Examples of medications targeted by these new standards are opioid agonists like codeine, oxycodone, hydromorphone, morphine and opioid combination products like oxycodone/acetaminophen, and hydrocodone/acetaminophen.
Also new on Jan. 1, 2024, is the Opioids Extended-Release Prior Authorization Quantity Limits (ER PAQL) program with Oxycontin as the lone target. Other opioid quantity limits which existed under AUO will continue under Opioids ER PAQL.
Questions: Visit the Pharmacy Programs page on BCBSMT.com provider website for more information.
Prime Therapeutics LLC is a pharmacy benefit management company. BCBSMT contracts with Prime to provide pharmacy benefit management and related other services. BCBSMT, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. MyPrime.com is an online resource offered by Prime Therapeutics.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.