Dose limits for Medicare members’ opioid prescriptions to take effect Jan. 1

The Centers for Medicare & Medicaid Services continues to combat the epidemic of prescription opioid abuse in the U.S. As a result, Blue Cross Blue Shield of Michigan and Blue Care Network will be required to establish a dose limitation for opioid drugs prescribed to our Medicare members. This change takes effect Jan. 1, 2017.

Safety limits for prescribed opioids
All Medicare prescription drug claims that include opioids and exceed a daily morphine equivalent dose of 250 mg will require a prior authorization before they may be dispensed at a pharmacy.

Blue Cross and BCN will calculate the daily morphine equivalent dose for each given Medicare member. We may deny an opioid prescription claim if the member’s cumulative morphine equivalent dose exceeds 250 mg across all of their claims. This daily cumulative morphine equivalent dose will be calculated using a Medicare member’s history of opioid prescription claims within our system.

Any opioid prescription claim or claims exceeding the 250 mg limit will require a prior authorization and clinical review by Blue Cross or BCN before the claims are covered at a pharmacy.

Known exceptions
CMS allows Medicare patients in certain situations to be excluded from this policy. Here are identified situations that are known exceptions from the daily morphine equivalent dose calculation:

• Hospice care
• Diagnoses or drug utilization history indicative of cancer
• Reasonable overlapping dispensing rates for prescription refills or new prescription orders for continuing fills
• Opioid usage previously determined by Blue Cross or BCN to be medically necessary through prior coverage determinations, prior authorization, pharmacy case management or appeals processes.

Prior authorization
Doctors who write prescriptions that exceed the safety limit must submit their prescriptions for a prior authorization. The prior authorization can be submitted by the doctor or his or her delegate. Please note:

• Documentation of medical necessity and acknowledgement of the significant clinical circumstance must be submitted to Blue Cross or BCN for a clinical review.

• The prescriber must demonstrate that the warranted amount of the opioid medication is needed to adequately manage the patient’s pain while being safe and appropriate.

For prior authorization, call our Clinical Help Desk at 1-800-437-3803 from 8 a.m. to 6 p.m. Monday through Friday.