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February 2017

CMS requires opioid dosing safety edit

Starting Jan. 1, 2017, the Centers for Medicare & Medicaid Services is requiring health care plans to do a point-of-sale safety edit on opioid drugs (see the full list of products below).

What you need to know

  • At the point of sale, an opioid claim will stop if it causes a member's cumulative, daily, morphine-equivalent dose to exceed 250 mg.
  • When a member's cumulative-daily dose exceeds the 250 mg morphine-equivalent dose, a Blue Cross Blue Shield of Michigan clinical review is required.
  • This could affect any opioid-prescribing doctor within a member's care model.
  • The doctor who orders the opioid prescription that exceeds the 250 mg threshold will be subject to the clinical review.
  • The edit can be resolved when the threshold-exceeding prescribing doctor or his or her delegate submits a prior-authorization request.

About the clinical review
You must submit medical-necessity documentation and acknowledge the significant clinical circumstance. The doctor must demonstrate the need for the prescribed amount of opioid medication. And the doctor must show that the medication will adequately manage the patient's pain and is safe and appropriate.

Helpful link
Use the Michigan Automated Prescription System to help you track a member's controlled substance prescription use. Find it at www.michigan.gov/mimapsinfo**.

List of opioid products

  • Butorphanol
  • Hydromorphone
  • Opium
  • Buprenorphine
  • Levorphanol
  • Oxycodone
  • Codeine
  • Meperidine
  • Oxymorphone
  • Dihydrocodeine
  • Methadone
  • Pentazocine
  • Fentanyl
  • Fentanyl citrate
  • Morphine
  • Tapentadol
  • Hydrocodone
  • Nalbuphine
  • Tramadol

**Blue Cross Blue Shield of Michigan does not control this website or endorse its general content.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.
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