12-26-2023
What’s new:
The BCBSTX Appropriate Use of Opioids (AUO) program will be retired effective January 1, 2024. However, we 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:
BCBSTX’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 (Opioids ER PAQL) program with Oxycontin as the lone target. The opioid quantity limits previously under AUO will be included under Prior Authorization and Step Therapy Programs under Program Criteria Summaries and Request Forms section.
If you have questions or concerns regarding this programs, please call Prime Therapeutics at 1-800-289-1525.