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  • June 2019

New criteria for opioid prior approvals

Effective July 1, members may need prior approval for the two opioid classes below:

Extended release opioids

  • Members currently on an extended release opioid as of July 1, will be allowed continuation of therapy for the same drug.
  • Requests for new opioid ER agents or changes in existing therapy, including quantities above the allowed limit, will be reviewed when member-specific documentation has been provided.

Immediate release opioids

  • Members currently on an immediate-release opioid therapy as of July 1, will be allowed continuation of therapy for the same drug.
  • Members new to therapy receiving a prescription for seven or fewer days and less than 50 morphine milligram equivalents (MME) per day will not require a prior approval.

Exception:
The program will allow for uses beyond these limits if the member has a diagnosis of cancer pain due to an active malignancy, is eligible for hospice care or has provided documentation showing use beyond these limits is appropriate.

Questions?
Encourage your employees to call Member Services using the number on the back of their ID cards.