Management of Opioid Therapy - PHARMACY POLICY 5.01.529 - Premera Blue Cross
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PHARMACY POLICY – 5.01.529
Management of Opioid Therapy
Effective Date: Sept. 1, 2021 RELATED MEDICAL POLICIES:
Last Revised: Aug. 3, 2021 None
Replaces: 5.01.579, 5.01.583
Select a hyperlink below to be directed to that section.
POLICY CRITERIA | CODING | RELATED INFORMATION
EVIDENCE REVIEW | REFERENCES | HISTORY
∞ Clicking this icon returns you to the hyperlinks menu above.
Introduction
Opioids are chemicals that bind to receptors in the brain or body. An opioid can be natural or
synthetic. Opioid medications can be used to manage certain types of pain. Opioids are
prescribed by and in consultation with a licensed healthcare professional. Examples of opioids
are oxycodone, hydrocodone, and fentanyl.
This policy describes when you have to take certain drugs before an opioid can be prescribed.
This policy also describes coverage criteria for quantities of some of the commonly prescribed
opioid medications when prescribed above the allowable limit. Quantity limits in this policy are
based on the maximum dose approved by the U.S. Food and Drug Administration. These dose
limits are the upper range that clinical trials show to provide a balance between safety and
effectiveness. Higher quantities may be approved based on adequate evidence from published
peer reviewed clinical studies, comprehensive medical records history, and the criteria below. It
is very easy to become dependent on opioids, and there is growing public concern about illegal
drug use. Sale of prescription opioids pills as well as heroin is growing rapidly. For this reason, it
is important to prescribe only as many opioid pills as a patient is expected to need. Properly
disposing of unused pills is also important for safety. To learn more about this, ask your
pharmacist or visit the FDA’s drug disposal page at
https://www.fda.gov/forconsumers/consumerupdates/ucm101653.htm.
Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to medical professionals. It is intended forproviders. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a
service may be covered.
Policy Coverage Criteria
Note: A copy of medical records history is required when submitting prior authorization
requests for the drugs affected by this policy.
Note: This policy applies to all formulary types across all lines of business (see Definition of
Terms below). As used in this policy, “Formulary” refers to the applicable formulary list
specified in a member’s contract.
Note: Dispensing quantity limits are not intended to apply in circumstances where logistics
may dictate otherwise. These circumstances include but are not limited to member
vacation or business travel, disruption of normal prescription supply chains due to
adverse weather events or other disasters and members living in remote areas where
travel to the nearest pharmacy may sometimes be problematic.
Click on the links below to be directed to that section of the policy:
Short-Acting Opioid Step Therapy Zohydro ER® (hydrocodone ER) and
hydrocodone bitartrate extended-release
Long-Acting Opioid Step Therapy
OxyContin® (oxycodone ER)
Long-Acting Opioid Quantity Limits
Transmucosal Fentanyl Citrate Products
Short-Acting Opioid Step Therapy
A quantity sufficient for a 7-day supply will be covered without prior authorization. Additional
quantities of BOTH brand and commercially available generic products for greater than a
7-day supply will require coverage review for opioid naïve patients. Opioid naïve is defined as
not having history of any opioid within the past 130 days.
Page | 2 of 21 ∞Short-Acting Opioid Step Therapy
For a list of applicable drugs, see the table in the Related Information section below.
Short-Acting Opioid, Greater Than 7-Day Supply: Medical Necessity
This policy does not apply to patients with cancer, sickle cell disease, or those in a
hospice program, end-of-life care, or palliative care.
Requests for more than 7 days of a short-acting opioid may be considered medically
necessary in patients who meet ALL of the following criteria:
• At least one trial of a non-opioid medication (eg, nonsteroidal anti-inflammatory drugs
[NSAIDs], acetaminophen) has provided an inadequate response, or non-opioid
medications are inappropriate according to the prescribing clinician
AND
• The patient’s history of controlled substance prescriptions has been checked within the
last 3 months using the state prescription drug monitoring program (PDMP), unless
unavailable in the state
Note: Exceptions may be medically necessary for certain clinical situations on a case-by-case
basis including but not limited to traumatic injury or surgeries with extended recovery time
Note: Documentation is required in the form of medical records for all reviews. All approvals
are provided one time only and, on a case-by-case basis.
Long-Acting Opioid Step Therapy
This step therapy is applicable to BOTH brand and commercially available generic
products. This policy does not apply to patients with cancer, sickle cell disease, or those
in a hospice program, end-of-life care, or palliative care.
This step therapy does not apply to methadone, Dolophine® and Methadose™ when
prescribed to treat opioid addiction (Opioid Use Disorder).
For a list of applicable drugs, see the table in the Related Information section below.
Long-Acting Opioid Therapy: Medical Necessity
Long-acting opioid may be considered medically necessary in patients with pain severe
enough to require daily, around-the-clock, long-term opioid treatment where patients
meet ALL of the following criteria:
• The patient has chronic pain and is not opioid naïve (opioid naïve is defined as not having
history of any opioid within the past 130 days)
Page | 3 of 21 ∞Long-Acting Opioid Step Therapy
AND
• Patient has a concurrent prescription or previous use of a short-acting opioid
AND
• Non-opioid therapies (eg, non-opioid medications [eg, nonsteroidal anti-inflammatory
drugs {NSAIDs}, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors
{SNRIs}, anticonvulsants], exercise therapy, weight loss, cognitive behavioral therapy) have
been optimized and are being used in conjunction with opioid therapy, or they have failed
according to the prescribing clinician
AND
• Treatment plan (including goals for pain and function) is in place and reassessments
(including pain levels and function) are scheduled at regular intervals according to the
prescribing clinician
AND
• The patient’s history of controlled substance prescriptions has been checked within the
last 3 months using the state prescription drug monitoring program (PDMP), unless
unavailable in the state
Note: Documentation is required in the form of medical records for all reviews. Approvals are
provided for one year in duration.
Long-Acting Opioid Quantity Limits
Coverage Guidelines for Quantity Limits that Exceed National Guidelines
This policy does not apply to patients with cancer, sickle cell disease or those in a
hospice program, end-of-life care, or palliative care.
ALL of the following criteria must be met for short-term approval to be granted:
• Patient is being seen by a board-certified pain specialist as defined by the American Board
of Medical Specialties (ABMS)
AND
• Patient has had trials of 2 or more non-pharmacologic therapies, such as physical therapy,
acupuncture, massage therapy, etc.
AND
• Patient has had trials of 3 or more non-opioid therapies, such as acetaminophen, NSAIDs,
gaba-analogues, tricyclic antidepressants, SNRI’s, etc.
AND
• Patient and the doctor have a pain management contract in place
Page | 4 of 21 ∞Long-Acting Opioid Quantity Limits
Coverage Guidelines for Quantity Limits that Exceed National Guidelines
AND
• Chart notes must include documentation that the (state-specific) Prescription Drug
Monitoring Program was checked in the last 3 months
AND
• Patient participates in urine drug screening as per frequency documented in the provider’s
chronic opioid therapy plan per medical records OR urine drug screening has been
documented within the last 6 months
Note: Requests may be approved on a case-by-case basis for a maximum of 3 months to
allow the provider time to reduce the dose to the allowed quantities (as described in the
Long-Acting Opioid Quantity Limit table below).
Note: Documentation is required in the form of medical records for all reviews
Dispensing Quantity Limits
Quantity limits apply to BOTH brand and commercially available generic products.
The following drugs have quantity limits that are of ALL strengths combined in 30 days:
• Arymo® ER, Embeda® ER, Exalgo®, hydromorphone ER, Kadian®, morphine sulfate ER,
Morphabond™ ER, MS Contin®, Nucynta® ER, Opana® ER, and oxymorphone ER
The following dispensing quantity limits are based on the maximum dose recommendations in
the product’s FDA-approved labeling. This information is available for each product at the
manufacturer’s web site or www.fda.gov. Opioid drugs with dispensing quantity limits are listed
in the following table:
Drug Dosage / Strength Quantity Limit Allowed
Without Review
Arymo® ER (morphine sulfate ER) 15 mg, 30 mg, 60 mg ER tablet Limit: 90 tablets per 30 days
Bunavail® (buprenorphine/naloxone) 2.1/0.3 mg, 4.2/0.7 mg buccal Limit: 90 films per fill
film
Bunavail® (buprenorphine/naloxone) 6.3/1 mg buccal film Limit: 60 films per fill
Embeda® (morphine sulfate 20mg/.08 mg, 30 mg/1.2 mg, Limit: 90 capsules per 30 days
ER/naltrexone HCl) 50mg/2 mg, 60 mg/2.4 mg, 80
Page | 5 of 21 ∞Drug Dosage / Strength Quantity Limit Allowed
Without Review
mg/3.2 mg, 100 mg/4 mg ER
capsule
Exalgo® (hydromorphone HCl ER) 8 mg, 12 mg, 16 mg, 32 mg ER Limit: 60 tablets per 30 days
tablet
Kadian® (morphine sulfate ER) 10 mg, 20 mg, 30 mg, 40 mg, Limit: 90 capsules per 30 days
50 mg, 60 mg, 80 mg, 100 mg,
200 mg ER capsule
Morphabond™ ER (morphine sulfate ER) 15 mg, 30 mg, 60 mg, 100 mg Limit: 60 tablets per 30 days
ER tablet
MS Contin® (morphine sulfate ER) 15 mg, 30 mg, 60 mg, 100 mg, Limit: 120 tablets per 30 days
200 mg ER tablet
Nucynta® (tapentadol HCl) 50 mg, 75 mg, 100 mg tablet Limit: 181 tablets per fill
Nucynta® ER (tapentadol HCl) 50 mg, 100 mg, 150 mg, 200 Limit: 60 tablets per 30 days
mg, 250 mg ER tablet
Opana® ER (oxymorphone HCl) 5 mg, 7.5 mg, 10 mg, 15 mg, 20 Limit: 90 tablets per 30 days
mg, 30 mg, 40 mg tablet
OxyContin® (oxycodone HCl ER) 10mg, 15 mg, 20 mg, 30 mg, 40 Limit: 90 tablets per 30 days
mg ER tablet
OxyContin® (oxycodone HCl ER) 60 mg, 80 mg ER tablet Limit: 120 tablets per 30 days
Suboxone® (buprenorphine/naloxone) 12/3 mg film Limit: 60 films per fill
Suboxone® (buprenorphine/naloxone) 2/0.5 mg, 4/1 mg, 8/2 mg film Limit: 90 films per fill
2/0.5 mg, 8/2 mg SL tablet
Zubsolv® (buprenorphine/naloxone) 0.7/0.18 mg, 1.4/0.36 mg, Limit: 90 tablets per fill
2.9/0.71 mg, 5.7/1.4 mg SL
tablet
Zubsolv® (buprenorphine/naloxone) 8.6/2.1 mg SL tablet Limit: 60 tablets per fill
Zubsolv® (buprenorphine/naloxone) 11.4/2.9 mg SL tablet Limit: 30 tablets per fill
Buprenorphine/naloxone (generic 12/3 mg film Limit: 60 films per fill
Suboxone®)
Buprenorphine/naloxone (generic 2/0.5 mg, 4/1 mg, 8/2 mg film Limit: 90 films per fill
Suboxone®)
2/0.5 mg, 8/2 mg SL tablet
Hydromorphone ER (generic Exalgo®) 8 mg, 12 mg, 16 mg, 32 mg Limit: 60 tablets per 30 days
tablet
Page | 6 of 21 ∞Drug Dosage / Strength Quantity Limit Allowed
Without Review
Morphine sulfate ER (generic Kadian®) 10 mg, 20 mg, 30 mg, 50 mg, Limit: 90 capsules per 30 days
60 mg, 80 mg, 100 mg, 200 mg
ER capsule
Morphine sulfate ER (generic MS 15 mg, 30 mg, 60 mg, 100 mg, Limit: 120 tablets per 30 days
Contin®) 200 mg ER tablet
Morphine sulfate ER, 24 HR (generic 30 mg, 45 mg, 60 mg, 75 mg, Limit: 60 capsules per 30 days
Avinza®) 90 mg, 120 mg capsule
Oxycodone HCl ER (generic OxyContin®) 10 mg, 15 mg, 20 mg, 30 mg, Limit: 90 tablets per 30 days
40 mg ER tablet
Oxycodone HCl ER (generic OxyContin®) 60 mg, 80 mg ER tablet Limit: 120 tablets per 30 days
Oxymorphone ER (generic Opana® ER) 5 mg, 7.5 mg, 10 mg, 15 mg, 20 Limit: 90 tablets per 30 days
mg, 30 mg, 40 mg ER tablet
Long-Acting Opioid Medical Necessity Criteria
Zohydro ER® (Hydrocodone Bitartrate Extended-Release) and Generic Hydrocodone
Bitartrate Extended-Release
Zohydro ER® (hydrocodone bitartrate extended-release) and generic hydrocodone
bitartrate extended-release may be considered medically necessary for the labeled
indication of the management of pain severe enough to require daily, around-the-clock,
long-term opioid treatment and for which alternative treatment options are inadequate.
Zohydro ER® (hydrocodone bitartrate extended-release) and generic hydrocodone
bitartrate extended-release may be covered when ALL of the following criteria are met:
• Treatment of severe chronic pain that requires around the clock opioid pain management
AND
• Documented therapeutic failure of 2 long-acting opioids (eg, fentanyl citrate, fentanyl
transdermal, hydromorphone, morphine ER, OxyContin®)
AND
• Patient is not under the age of 19 years old
AND
• Quantity is not over 60 capsules per 30 days
AND
• In the event that a request is received that does not meet criteria for approval but is of a
sufficiently high dose that would require tapering, a 3-month approval may be authorized to
Page | 7 of 21 ∞Long-Acting Opioid Medical Necessity Criteria
allow the provider time to reduce the dose to the allowed quantities above. These requests
may be approved on a case-by-case basis and are subject to a clinical review for medical
necessity.
In the event where tapering cannot be achieved within a 3-months period, ALL of the
following additional criteria must be met for approval to be granted:
• Patient is being seen by a board-certified pain specialist
AND
• Patient and the doctor have a pain management contract in place
AND
• Patient has had trials of other non-pharmacologic therapies, such as physical therapy,
acupuncture, massage therapy, etc.
AND
• Chart notes must include (state-specific) Prescription Drug Monitoring Program summary
report (last 3 months)
AND
• Patient participates in urine drug screening tests (last 3 months)
Note: First-time approvals will be covered for a period of 3 months (case-dependent). For
continuation of coverage beyond the first 3 months new case review will be required. In addition,
short term approvals may be given on a case-by-case basis when clinical rationale has been
submitted by a provider indicating that a tapering dose is being attempted, and patient is
expected to reach dosing of 120 Morphine Milligram Equivalent (MME) or less by the end of the 3
months. These requests are subject to a clinical review for medical necessity.
OxyContin® (oxycodone ER)
Extended-release oxycodone (OxyContin®) may be considered medically necessary for the
labeled indication of the management of pain severe enough to require daily, around-the-
clock, long-term opioid treatment and for which alternative treatment options are
inadequate.
Extended-release oxycodone (OxyContin®) may be covered when ALL of the following
criteria are met:
• The quantity is not over three tablets per day of OxyContin 10 mg, 15 mg, 20 mg, 30 mg, 40
mg OR four tablets per day of OxyContin 60 mg and 80 mg.
AND
Page | 8 of 21 ∞Long-Acting Opioid Medical Necessity Criteria
• In the event that a request is received that does not meet criteria for approval but is of a
sufficiently high dose that would require tapering, a 3-month approval may be authorized to
allow the provider time to reduce the dose to the allowed quantities above. These requests
may be approved on a case-by-case basis and are subject to a clinical review for medical
necessity.
In the event where tapering cannot be achieved within a 3-months period ALL of the
following criteria must be met for approval to be granted:
• Medication is being prescribed by or in consultation with a board-certified pain specialist as
defined by the American Board of Medical Specialties (ABMS), OR by a licensed health
professional with extensive training/experience in pain management.
AND
• Patient and the doctor have a pain management contract in place
AND
• Patient has had trials of other non-pharmacologic therapies, such as physical therapy,
acupuncture, massage therapy, etc.
AND
• Chart notes must include (state-specific) Prescription Drug Monitoring Program summary
report (last 3 months)
AND
• Patient participates in urine drug screening tests (last 3 months)
Note: First-time approvals will be covered for a period of 3 months (case-dependent). For
continuation of coverage beyond the first 3 months new case review will be required. In addition,
short term approvals may be given on a case-by-case basis when clinical rationale has been
submitted by a provider indicating that a tapering dose is being attempted, and patient is
expected to reach ≤120 Morphine Milligram Equivalent (MME) dosing by the end of the 3 months.
These requests are subject to a clinical review for medical necessity.
Note: Quantity limit requests that are the result of a lower strength tablet being used in multiples
that could be achieved with a higher dose tablet (ie, three 20mg tablets versus one 60mg tablet)
will not be approved. In certain circumstances, an approval may be given based on clinical
rationale submitted and would be subject to a review for medical necessity.
Transmucosal Fentanyl Citrate Products
Page | 9 of 21 ∞Long-Acting Opioid Medical Necessity Criteria
Transmucosal fentanyl citrate products (eg, Abstral®, Actiq®, Fentora™, Lazanda®,
Onsolis™, Subsys®) may be considered medically necessary for the treatment of
breakthrough cancer pain in adult patients with compromised oral intake or absorption.
Coding
N/A
Related Information
Short-Acting Opioid, Greater Than 7-Day Supply: Drugs
Acetaminophen with codeine: Oral suspension, tablet
• Tylenol® with codeine
Acetaminophen/caffeine/dihydrocodeine: Capsule, tablet
• Trezix™
Aspirin/caffeine/dihydrocodeine: Capsule
• Synalgos®-DC
Belladonna and Opium: Suppository
Benzhydrocodone/acetaminophen
• Apadaz™
• Benzhydrocodone/acetaminophen
Buprenorphine: Injection
• Buprenex®
Butalbital/acetaminophen/caffeine/codeine: Capsule
• Fioricet® with Codeine
Butorphanol: Injection, nasal spray
• Butorphanol Tartrate Novaplus
Carisoprodol/aspirin/codeine: Tablet
Codeine sulfate: Tablet
Codeine/butalbital/aspirin/caffeine: Capsule
• Fiorinal® with Codeine
Hydrocodone/acetaminophen: Oral elixir, oral solution, oral tablet
• Hycet®
Page | 10 of 21 ∞Short-Acting Opioid, Greater Than 7-Day Supply: Drugs
• Lorcet®, Lorcet HD®, Lorcet Plus®
• Lortab®, Lortab® Elixir
• Norco®
• Verdrocet®
• Vicodin®, Vicodin ES®, Vicodin HP®
• Xodol®
Hydrocodone/ibuprofen: Tablet
• Ibudone®
• Reprexain™
• Vicoprofen®
• Xylon™
Hydromorphone: Injection, oral solution, rectal suppository, tablet
• Dilaudid®, Simplist Dilaudid®
Ibuprofen/oxycodone: Tablet
Levorphanol: Tablet
Meperidine: Injection, oral solution, oral syrup, tablet
• Demerol®, Meperitab™
Morphine: Injection, oral solution, rectal suppository, tablet
• Duramorph®
• Infumorph®
• Mitigo®
Nalbuphine: Injection
• Nalbuphine HCl Novaplus
Oxycodone: Capsule, injection, oral concentrate, oral solution, tablet
• Oxaydo®
• Oxy IR®
• Roxicodone®
• Roxybond™
Oxycodone/acetaminophen: Tablet, solution
• Endocet®
• Nalocet®
• Oxycodone HCl-Acetaminophen AvPak™
• Percocet®
• Primlev™
• Prolate™
Oxycodone/aspirin: Tablet
• Percodan®
Oxymorphone: Tablet
• Opana®
Page | 11 of 21 ∞Short-Acting Opioid, Greater Than 7-Day Supply: Drugs
Pentazocine lactate: Injection
• Talwin®
Pentazocine/naloxone: Tablet
Tapentadol: Tablet
• Nucynta®
Tramadol: Oral suspension, tablet
• FusePaq Synapryn™
• Ultram®
Tramadol/acetaminophen: Tablet
• Ultracet®
Long-Acting Opioid Therapy: Drugs
Buprenorphine: Buccal film, injection, intradermal implant, transdermal patch
• Belbuca®
• Buprenex®
• Buprenorphine patch
• Butrans®
Fentanyl: Transdermal patch
• Duragesic®
• Fentanyl Transdermal System Novaplus
• Ionsys®
Hydrocodone ER: Capsule, tablet
• Hysingla® ER
• Zohydro® ER
Hydromorphone ER: Tablet
• Exalgo®
Methadone: Injection, oral solution, tablet, tablet for suspension
• Diskets® Dispersible
• Dolophine® HCl
• Methadol HCl Intensol™
• Methadose™
Morphine sulfate ER: Capsule, tablet
• Arymo® ER
• Kadian®
• Morphabond ER™
• MS Contin®
Morphine sulfate and naltrexone ER: Capsule
• Embeda®
Page | 12 of 21 ∞Long-Acting Opioid Therapy: Drugs
Oxycodone HCl ER: Tablet
• OxyContin® ER
Oxycodone ER: Capsule
• Xtampza® ER
Oxymorphone ER: Tablet
• Opana® ER
Tapentadol ER: Tablet
• Nucynta® ER
Tramadol ER: Capsule, tablet
• Conzip™
• Ultram® ER
Benefit Application
This policy is managed through the Pharmacy Benefit. It applies to all pharmacy benefit
contracts that include Pharmacy Prior Authorization Edits.
Definition of Terms
Formulary: A formulary is a list of drugs approved by the Pharmacy and Therapeutics
Committee (P&T) for routine use. A well-designed formulary should provide adequate drug
selection to meet the treatment needs of most patients; however, there will always be
exceptional cases where a non-formulary drug may be the best therapeutic choice.
Formulary drug: A formulary drug (also known as a preferred drug) is a drug that is on the
formulary list. Drugs that are not on the list are referred to as non-formulary drugs.
Label: Product label refers to the FDA approved prescribing information that is available for
every legend drug approved for use in the U.S. The label includes indications, contraindications,
recommended dosing, warnings, precautions, side effects, drug interactions, and information on
safety in pregnancy and other special populations. The drug’s pharmacology, pharmacokinetics,
and available dosage forms are also provided. The current format also includes a summary of
the pivotal clinical trials that were submitted to FDA in support of the New Drug Application.
This prescribing information is included as a package insert with the product and is available on
the manufacturer’s web site.
Page | 13 of 21 ∞Quantity limits: A quantity limit is the maximum amount of a medication that may be
dispensed during a given calendar period or at one prescription fill without an exception
request. Dispensing of a larger quantity may be approved, based on individual case review. A
specified larger quantity may be approved when patient-specific circumstances require it, or
when published clinical evidence supports a higher dose protocol.
Evidence Review
Background
Opioid analgesics are commonly used for the management of pain. An estimated 20% of
patients presenting to physician offices with pain symptoms or pain-related diagnoses
(including acute and chronic pain) unrelated to cancer receive an opioid prescription.
Short-acting opioids are indicated for the management of pain severe enough to require an
opioid analgesic. The objective of this quantity limit is to restrict the initial days’ supply of short-
acting opioids to seven days, thus decreasing the quantity dispensed to align with current
guidelines and prevent stockpiling and/or misuse.
The currently available long-acting (due to either an extended-release formulation or a long
half-life [ie, methadone]) opioids are buprenorphine, hydrocodone, hydromorphone,
methadone, morphine sulfate, oxycodone, oxymorphone, tapentadol, and tramadol. All of the
long-acting opioids are indicated for the management of pain severe enough to require daily,
around-the-clock, long-term opioid treatment and for which alternative treatment options are
inadequate. Extended-release opioid dosage forms offer a long duration of effect, reduce
severity of end-of-dose pain, and allow many patients to sleep through the night. Long-acting
products should be prescribed with an immediate-release dosage form, to be used as needed
for breakthrough pain.
Description
Analgesics are used to treat a wide variety of pain syndromes. Traditionally, these have been
classified in three groups: acute pain, chronic cancer pain and chronic pain in non-cancer
patients. Each requires a different approach. In acute pain the goal is to keep the patient
comfortable while avoiding respiratory depression and minimizing the potential of opioid
Page | 14 of 21 ∞dependence. Oncology patients are managed to achieve the best functional balance of
analgesia versus sedation. No maximum dose limits exist in this setting, while chronic non-
cancer pain should be managed with regimens that combine drugs from different
pharmacologic classes to minimize opioid use (eg, antidepressants, NSAIDs or acetaminophen,
muscle relaxants, and anticonvulsants).
Opioid Abuse
Abuse of prescription opioid products is a growing concern. The 2006 National Survey on Drug
Use and Health (NSDUH) found 4.7 million people used a prescription opioid for non-medical
purposes in the month prior to the survey. More than 2 million per year are considered new
illicit users of prescription opioids, a 5-fold increase from the 1980s. For people older than age
12 in 2007, more began illicitly using opioids than marijuana, cocaine, or any other illegal drug.
In addition to abuse of opioids, prescriptions of opioids for pain are also increasing. From 1992
to 2002 prescriptions for opioids increased 154% while the U.S. population increased 13%.
Along with this increase in legitimate and illicit use of opioids has come an increase in ER visits
and deaths due to opioids use.
• The public health surveillance system, Drug Abuse Warning System (DAWN), last published
data on drug related emergency visits from 2008 and found the largest number of ER visits
occurred with oxycodone combinations (105,214) followed by hydrocodone combinations
(89,051), and then methadone (63,629). These numbers have increased dramatically from
2004 with a 152% increase for oxycodone, 123% with hydrocodone, and 73% with
methadone (all pWhile it is clear that use of and adverse events caused by opioids are increasing, the data do not
differentiate between events due to increased legitimate prescribing for pain and those due to
illicit use. Additionally, as the number of total exposures to each drug is unknown, it is difficult
to determine the risk associated with each drug due to lack of a meaningful denominator.
In 2010, the Washington State Legislature passed a statute requiring professional boards to
draft regulations managing high-dose opioid use, clearly recognized as a serious threat to
public health.
Extended-Release Oxycodone
The purpose of the OxyContin® quantity limit is fourfold:
• Reduce unnecessarily large quantities from being dispensed, thereby decreasing the
likelihood of unnecessary tablets remaining in medicine cabinets where relatives and other
visitors to the home could pilfer them.
• Remind prescribers to select a larger tablet size when increasing the dose, rather than
ordering two tablets to be taken at one time.
• Serve as a warning signal is cases where a patient may be using part of the prescription non-
medically, or may be diverting pills for use by others for whom they were not prescribed.
OxyContin® is normally dosed every 12 hours and is designed to be administered as 2 tablets
per day. In individuals with more-rapid-than-normal clearance of oxycodone, or other unusual
clinical circumstances, it is likely that 3 per day would be required. By setting the limit at 3, the
Plan allows for flexibility on the part of practitioners and their patients. OxyContin is available in
tablet sizes of 10, 15, 20, 30, 40, 60, and 80 mg. When the 80mg tablet size is reached, the
patient should be receiving 160mg/day. For cancer patients needing to go beyond this dose, the
4 tablet limit allows a further escalation to 320mg/day before approval of a quantity override
would be needed. Exception for medical necessity will be routinely given when the patient is
being treated for cancer pain and has reached the maximum dosage achievable with 4 tablets
per day.
Page | 16 of 21 ∞Transmucosal Fentanyl
Transmucosal fentanyl agents are potent analgesics approved for the treatment of breakthrough
pain in opioid-treated and tolerant cancer patients. There is no fully published randomized
controlled evidence for use of these products for non-cancer pain at this time.
Availability of longer-term safety/tolerability data with Fentora® is limited. Because life-
threatening respiratory depression could occur at any dose in opioid non-tolerant patients,
Fentora® and Actiq® are contraindicated in the management of acute or postoperative pain,
and for use in opioid non-tolerant patients. A unique adverse event issue identified with use of
Fentora® is application site reactions, including ulceration. Risk is difficult to define, due to the
limited number of patients and duration of exposure to this formulation in clinical trials. This
side effect has the potential to alter the formulation’s absorption characteristics and may
increase risk for serious side effects in some patients. To ensure safety, a cautious approach to
use of either transmucosal fentanyl product is warranted.
Management of chronic severe pain in cancer patients requires the effective use of long-acting
opioids, supplemented with limited doses of a short-acting opioid (rescue medication). Excessive
doses of rescue medication usually indicate suboptimal pain control. This problem can be
alleviated by increasing the fraction of the total daily opioid dose given as long-acting opioid.
2019 Updates
A literature search was conducted from October 1, 2018, to November 1, 2019, and no new
evidence was found that would change this policy. Review of FDA labeling updates for long-
acting opioids in this policy found no new evidence that would change the quantity limits listed
on this policy.
2021 Updates
A literature search was conducted from July 1, 2020, to June 30, 2021, and no new evidence was
found that would change this policy.
References
Page | 17 of 21 ∞1. Silverstein FE, Faich G, Goldstein JL et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for
osteoarthritis and rheumatoid arthritis: The CLASS study: A randomized controlled trial. Celecoxib Long-term Arthritis Safety
Study. JAMA 2000; 284:1247-55.
2. Bombardier C, Laine L, Reicin A et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with
rheumatoid arthritis. (VIGOR) NEJM 2000; 343:1520-28.
3. Lai KC, Chu KM, Hui WM, et al. Celecoxib compared with lansoprazole and naproxen to prevent gastrointestinal ulcer
complications. Am J Med. 2005 Nov;118(11):1271-8.
4. Chan FK, Hung LC, Suen BY, et al. Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in
patients with arthritis. NEJM. 2002 Dec 26;347(26):2104-10.
5. Celecoxib plus aspirin versus naproxen and lansoprazole plus aspirin: a randomized, double-blind, endoscopic trial. Clin
Gastroenterol Hepatol. 2007 Oct;5(10):1167-74.
6. Coluzzi PH, Schwartzberg L, Conroy JD et al. Breakthrough cancer pain: a randomized trail comparing oral transmucosal
fentanyl citrate (OFTC®) and morphine sulfate immediate release (MSIR®). Pain. 2001;91:123-130.
7. Payne R, Coluzzi P, Hart L et al. Long-term safety of oral transmucosal fentanyl citrate for breakthrough cancer pain. J Pain
Symptom Manage. 2001;22:575-583.
8. Farrar JT, Cleary J, Rauck R et al. Oral transmucosal fentanyl citrate: randomized, double-blind, placebo-controlled trial for
treatment of breakthrough pain in cancer patients. J Natl Cancer Inst. 1998;90:611-616.
9. SAMHSA. Results from the 2006 National Survey on Drug Use and Health: national findings. Rockville, MD: Substance Abuse
and Mental Health Services Administration; 2007b.
10. US Department of Health and Human Services, substance abuse and mental health services administration. Results from the
2007 national survey on drug use and health: national findings. NSDUH Series H-34, DSHS Publication No. SMA 08-4343.
Rockville, MD: Office of Applied Studies, 2008.
11. Webster, L. Update on Abuse-resistant and abuse-deterrent approaches to opioid formulations. Pain Med 2009;10 Suppl
2:S124-S133.
12. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits [online]. Available
online: https://www.samhsa.gov/data/sites/default/files/DAWN2k11ED/DAWN2k11ED/DAWN2k11ED.pdf Accessed July
29, 2021.
13. Moore TJ, Cohen MR and Furberg CD. Serious adverse drug events reported to the Food and Drug Administration, 1998-2005.
Arch Intern Med 2007;167 (16):1752-1759.
14. Coolen P, Best S, Lima A, et al. Overdose deaths involving prescription opioids among Medicaid enrollees – Washington, 2004-
2007. MMWR 2009;58(42):1171-1175.
15. US Department of Health and Human Services, Substance Abuse and Mental Health Services. Summary report of the meeting:
methadone mortality – a reassessment.
16. Walsh SL, Nuzzo PA, Lofwall MR and Holtman JR. The relative abuse liability of oral oxycodone, hydrocodone, and
hydromorphone assessed in prescription opioid abusers. Drug Alcohol Depend 2008;98(3):191-202.
17. Twycross R, Prommer E, Mihalyo M, Wilcock A. Fentanyl (transmucosal). J Pain Symptom Management 2012;44(1):131-149.
18. Nalamachu S, Rauck R, Dilaha L, Parikh N. Lack of correlation between the dose of fentanyl sublingual spray for breakthrough
cancer pain and the dose of around-the-clock opioid for persistent pain. J Pain 2013;14:S74.
19. Zeppetella G, Davies AN. Opioids for the management of breakthrough pain in cancer patients. Cochrane Database Syst Rev
2013; Oct 21;10:CD004311. doi: 10.1002/14651858.CD004311.pub3.
20. Friedrichsdorf SJ, Postier A. Management of breakthrough pain in children with cancer. J Pain Research 2014;7:117-123.
21. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR
Recomm Rep 2016; 65:1–49. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm Accessed August 30, 2021.
Page | 18 of 21 ∞22. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR
Recommendations and Reports. 2016;65(1):1-49.
23. Nucynta ER extended-release oral tablets [prescribing information]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; Revised March
2021.
24. Embeda extended-release capsules [prescribing information]. Bristol, TN: King Pharmaceuticals, Inc.; Revised October 2019.
25. Kadian capsules [prescribing information]. Parsippany, NJ: Actavis Pharma, Inc.; Revised March 2021.
26. Avinza® capsules [prescribing information]. New York, NY: Pfizer Inc.; Revised April 2014.
27. MS Contin tablets [prescribing information]. Stamford, CT: Purdue Frederick; Revised March 2021.
28. Oramorph SR tablets [prescribing information]. Columbus, OH: Roxane Laboratories; Revised February 2006.
29. OxyContin tablets [prescribing information]. Stamford, CT: Purdue Pharma LP; Revised March 2021.
30. Opana ER tablets [prescribing information]. Malvern, PA: Endo Pharmaceuticals; Revised March 2021.
31. Exalgo extended-release tablets [prescribing information]. Hazelwood, MO: Mallinckrodt Brand Pharmaceuticals, Inc.; Revised
October 2019.
32. Zohydro ER extended-release capsules [prescribing information]. San Diego, CA: Zogenix, Inc; Revised March 2021.
33. Hysingla™ ER extended-release tablets [prescribing information]. Stamford, CT: Purdue Phharma L.P.; Revised March 2021.
34. Xtampza ER™ extended-release capsules [prescribing information]. Cincinnati, OH: Patheon Pharmaceuticals; Revised March
2021.
35. Arymo™ ER extended-release tablets [prescribing information]. Stamford, CT: Purdue Pharma LP; Revised October 2019.
36. Conzip extended-release capsules [prescribing information]. Sayreville, NJ: Vertical Pharmaceuticals, LLC; Revised March 2021.
37. Dolophine [prescribing information]. Eatontown, NJ: West-Ward Pharmaceuticals Corp.; Revised June 2021.
38. Belbuca™ buccal film [prescribing information]. Raleigh, NC: BioDelivery Sciences International, Inc.; Revised March 2021.
39. Motheral BR, Henderson R, Cox ER. Plan sponsor savings and member experience with point-of-service prescription step
therapy. Am J Manag Care 2004;10:457-464.
40. Morley CP, Badolato DJ, Hickner J, et al. The impact of prior authorization requirements on primary care physician’s offices:
report of two parallel network studies. J Am Board Fam Med. 2013;26(1):93-95.
41. Funkenstein A, Malowney M, Boyd JW. Insurance Prior Authorization Approval Does Not Substantially Lengthen the Emergency
Department Length of Stay for Patients With Psychiatric Conditions Ann Emerg Med 2013;61(5):596-597.
42. Hoadley JF, Merrell K, Hargrave E, et al. In Medicare Part D plans, low or zero copay and other features to encourage the use of
generics could save billions. Health Aff (Millwood) 2012;31(10):2266-2275.
43. Lu CY, Law MR, Soumerai SB, et al. Impact of prior authorization on the use and costs of lipid-lowering medications among
Michigan and Indiana dual enrollees in Medicaid and Medicare: results of a longitudinal, population-based study. Clin Ther.
2011;33(1):135-44.
44. Law MR, Lu CY, Soumerai SB, et al. Impact of prior authorization on the use and costs of lipid-lowering medications among
Michigan and Indiana dual enrollees in Medicaid and Medicare: results of a longitudinal, population-based study. Clin Ther.
2011;33(1):135-44.
45. 21 CFR 201.5: Labeling Requirements for Prescription Drugs. Adequate Directions for Use. Available at
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?CFRPart=201 Accessed August 30, 2021.
46. Apadaz [prescribing information]. Coralville, IA. KemPharm, Inc.; Revised March 2021.
Page | 19 of 21 ∞History
Date Comments
02/08/11 Add to Prescription Drug Section - New Policy.
12/13/11 Replace Policy – Policy updated with additional approval parameters and dosing
limitation for OxyContin.
11/13/12 Replace policy. A literature search did not indicate the need to update the criteria in
this policy.
03/15/13 Update Related Policies. Add 5.01.542.
07/08/13 Minor Update – Clarification was added to the policy that it is managed through the
member’s pharmacy benefit; this is now listed in the header and within the coding
section.
10/14/13 Replace policy. Medically necessary policy statement for OxyContin updated with new
FDA labeling and stricter FDA indication wording.
04/14/14 Annual review. Policy updated with extended-release hydrocodone (Zohydro ER®) as
medically necessary for the labeled indication of the management of pain severe
enough to require daily, around-the-clock, long-term opioid treatment and for which
alternative treatment options are inadequate.
12/01/14 Update Related Policies. Add 5.01.546.
10/13/15 Annual Review. Policy statements for Cox-II (Celebrex) removed as this medication no
longer requires prior authorization. Title updated, removed “Non-Opiod” as this only
pertained to Celebrex.
02/09/16 Annual Review. Criteria for Zohydro ER removed from Policy Guidelines: concomitant
therapy with CNS depressants or inhibitors of CYP3A4; no history of COPD; and, no
current or recent head injury.
05/01/16 Interim update, approved April 12, 2016. Additional criteria for OxyContin® and
Zohydro® ER quantity limit are included.
01/01/17 Interim Update, approved December 13, 2016. Quantity limit criteria for transmucosal
fentanyl products (TIRFs) has been removed.
06/01/17 Annual Review, approved May 23, 2017. Policy moved into new format. Created
introduction summary and removed the word “preferred” from the coverage criteria
for Zohydro ER. Medical records requirement statement is now included in the policy.
10/01/18 Annual Review, approved September 11, 2018. Significant revision of the policy; added
contents of policy 5.01.579 and 5.01.583 to this policy. Title changed from “Opioid
Analgesics“ to “Management of Opioid Therapy”.
Page | 20 of 21 ∞Date Comments
05/01/19 Interim Review, approved April 2, 2019. Added Apadaz™ (benzhydrocodone and
acetaminophen) and benzhydrocodone/acetaminophen to short-acting opioid
therapy. Added buprenorphine patch to long-acting opioid therapy.
07/01/19 Interim Review, approved June 4, 2019. Removed Sublocade and Probuphine under
long-acting opioid therapy.
01/01/20 Annual Review, approved December 10, 2019. No changes to policy statement.
03/01/20 Interim Review, approved February 20, 2020. For the Long-Acting Opioid Step Therapy
criteria added an exception for methadone, Dolophine® and Methadose™ when
prescribed to treat opioid addiction. Added generic hydrocodone bitartrate extended-
release to policy.
04/01/20 Interim Review, approved March 19, 2020. Added sickle cell disease as a condition for
when coverage criteria do not apply.
09/01/20 Annual Review, approved August 20, 2020. No changes to policy statement. Added
Prolate (oxycodone and acetaminophen) to the short-acting opioid table.
09/01/21 Annual Review, approved August 3, 2021. No changes to policy statement.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The
Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and
local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review
and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit
booklet or contact a member service representative to determine coverage for a specific medical service or supply.
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2021 Premera
All Rights Reserved.
Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when
determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to
the limits and conditions of the member benefit plan. Members and their providers should consult the member
benefit booklet or contact a customer service representative to determine whether there are any benefit limitations
applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
Page | 21 of 21 ∞Discrimination is Against the Law Oromoo (Cushite):
Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa
Premera Blue Cross complies with applicable Federal civil rights laws and yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee
does not discriminate on the basis of race, color, national origin, age, odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa
disability, or sex. Premera does not exclude people or treat them differently ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf
because of race, color, national origin, age, disability or sex. yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan
jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin
Premera: odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu.
• Provides free aids and services to people with disabilities to communicate Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa.
effectively with us, such as:
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English, such as: devrez peut-être prendre des mesures par certains délais pour maintenir
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d'obtenir cette information et de l’aide dans votre langue à aucun coût.
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Appelez le 800-722-1471 (TTY: 800-842-5357).
If you need these services, contact the Civil Rights Coordinator.
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If you believe that Premera has failed to provide these services or
enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti
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avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka
Civil Rights Coordinator - Complaints and Appeals
kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo.
PO Box 91102, Seattle, WA 98111
Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a,
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san ou pa gen pou peye pou sa. Rele nan 800-722-1471
Email AppealsDepartmentInquiries@Premera.com
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You can file a grievance in person or by mail, fax, or email. If you need help
Deutsche (German):
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Diese Benachrichtigung enthält wichtige Informationen. Diese
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Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten
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ລາວ (Lao):
Fa’asamoa (Samoan):
ແຈ້ ງການນ້ີມີຂໍ້ ມູ ນສໍາຄັ ນ. ແຈ້ ງການນ້ີອາດຈະມີຂ້ໍ ມູ ນສໍາຄັ ນກ່ ຽວກັ ບຄໍາຮ້ ອງສະ Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau
ໝັ ກ ຫືຼ ຄວາມຄຸ້ ມຄອງປະກັ ນໄພຂອງທ່ ານຜ່ ານ Premera Blue Cross. ອາດຈະມີ ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala
ວັ ນທີສໍາຄັ ນໃນແຈ້ ງການນ້ີ. ທ່ ານອາດຈະຈໍາເປັນຕ້ ອງດໍາເນີນການຕາມກໍານົ ດ atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua
ເວລາສະເພາະເພ່ືອຮັ ກສາຄວາມຄຸ້ ມຄອງປະກັ ນສຸ ຂະພາບ ຫືຼ ຄວາມຊ່ ວຍເຫືຼອເລ່ືອງ atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei
fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le
ຄ່ າໃຊ້ ຈ່ າຍຂອງທ່ ານໄວ້ . ທ່ ານມີສິດໄດ້ ຮັ ບຂ້ໍມູ ນນ້ີ ແລະ ຄວາມຊ່ ວຍເຫືຼອເປັນພາສາ aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai
ຂອງທ່ ານໂດຍບໍ່ເສຍຄ່ າ. ໃຫ້ ໂທຫາ 800-722-1471 (TTY: 800-842-5357). i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua
atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i
ភាសាែខម រ (Khmer): ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471
(TTY: 800-842-5357).
េសចកត ជ
ី ូនដំណឹងេនះមានព័ត៌មានយា៉ងសខាន។ ំ ់ េសចកត ីជូ នដំណឹងេនះរបែហល
ជាមានព័តមានយា
៌ ៉ ងសំខាន់អំពីទរមងែបបបទ
់ ឬការរា៉ ប់រងរបស់អន កតាមរយៈ Español (Spanish):
Premera Blue Cross ។ របែហលជាមាន កាលបរេចទស ិ ឆ ំខានេនៅកងេសចក
់ នុ តជ
ី ូន Este Aviso contiene información importante. Es posible que este aviso
contenga información importante acerca de su solicitud o cobertura a
ដំណងេនះ។
ឹ អន ករបែហលជារតូវការបេញញសមតភាព ច ថ ដលកណតៃថ
់ ំ ់ ង ជាក់ចបាស់
través de Premera Blue Cross. Es posible que haya fechas clave en este
នានា េដើមបីនឹងរកសាទុកការធានារា៉ បរងស ់ ុ ខភាពរបស ់អន ក ឬរបាក់ជំនួ យេចញៃថល ។ aviso. Es posible que deba tomar alguna medida antes de determinadas
អន កមានសិទិធ ទទលព័
ួ ត៌មានេនះ និងជំនួ យេនៅកុន ងភាសារបសអ ់ ន កេដាយមិនអស fechas para mantener su cobertura médica o ayuda con los costos. Usted
លុយេឡយ។ើ សមទ
ូ ូ រស័ពទ 800-722-1471 (TTY: 800-842-5357)។ tiene derecho a recibir esta información y ayuda en su idioma sin costo
alguno. Llame al 800-722-1471 (TTY: 800-842-5357).
ਪੰ ਜਾਬੀ (Punjabi): Tagalog (Tagalog):
ਇਸ ਨੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹ.ੈ ਇਸ ਨੋ ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ਤੁਹਾਡੀ Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang
ਕਵਰਜ ੇ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹੱ ਤਵਪਰਨ ੂ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨੋ ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon
ਹੋ ਸਕਦੀਆਂ ਹਨ. ਜੇਕਰ ਤਸੀ ੁ ਜਸਹਤ ਕਵਰਜ ੇ ਿਰਖਣੀੱ ਹਵੋ ੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵਚੱ ਮਦਦ ਦੇ tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue
Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring
ਇਛੱ ੁਕ ਹੋ ਤਾਂ ਤੁਹਾਨੰ ੂ ਅੰ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੱ ੁਕਣ ਦੀ ਲੜੋ ਹੋ ਸਕਦੀ ਹੈ ,ਤੁਹਾਨੰ ੂ mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang
ਮਫ਼ਤੁ ਿਵਚ
ੱ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪਾਪਤ ੍ਰ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na
800-722-1471 (TTY: 800-842-5357). walang gastos. May karapatan ka na makakuha ng ganitong impormasyon
at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471
( فارسیFarsi): (TTY: 800-842-5357).
اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم. اين اعالميه حاوی اطالعات مھم ميباشد
به تاريخ ھای مھم در. باشدPremera Blue Cross تقاضا و يا پوشش بيمه ای شما از طريق ไทย (Thai):
شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه. اين اعالميه توجه نماييد ประกาศนมขอมลสาคญ
้ี ี ้ ู ํ ั ประกาศนอาจมขอมลทสาคญเกยวกบการการสมครหรอขอบเขตประกน
้ี ี ้ ู ่ี ํ ั ่ี ั ั ื ั
شما حق. به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد،ھای درمانی تان สขภาพของคณผาน
ุ ุ ่ Premera Blue Cross และอาจมกาหนดการในประกาศน
ีํ ี ้ คณอาจจะตอง
ุ ้
برای کسب.اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد
( تماس800-842-5357 تماس باشمارهTTY )کاربران800-722-1471 اطالعات با شماره ดาเนนการภายในกาหนดระยะเวลาทแนนอนเพอจะรกษาการประกนสขภาพของคณหรอการชวยเหลอท
ํ ิ ํ ่ี ่ ่ื ั ั ุ ุ ื ่ ื ่ี
.برقرار نماييد มคาใชจาย
ี ่ ้ ่ คณมสทธทจะไดรบขอมลและความชวยเหลอนในภาษาของคณโดยไม่
ุ ี ิ ิ ่ี ้ ั ้ ู ่ ื ้ี ุ มีคาใชจาย
่ ้ ่ โทร
800-722-1471 (TTY: 800-842-5357)
Polskie (Polish):
To ogłoszenie może zawierać ważne informacje. To ogłoszenie może Український (Ukrainian):
zawierać ważne informacje odnośnie Państwa wniosku lub zakresu Це повідомлення містить важливу інформацію. Це повідомлення
świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na може містити важливу інформацію про Ваше звернення щодо
kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie страхувального покриття через Premera Blue Cross. Зверніть увагу на
przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub ключові дати, які можуть бути вказані у цьому повідомленні. Існує
pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej імовірність того, що Вам треба буде здійснити певні кроки у конкретні
informacji we własnym języku. Zadzwońcie pod 800-722-1471 кінцеві строки для того, щоб зберегти Ваше медичне страхування або
(TTY: 800-842-5357). отримати фінансову допомогу. У Вас є право на отримання цієї
інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за
Português (Portuguese): номером телефону 800-722-1471 (TTY: 800-842-5357).
Este aviso contém informações importantes. Este aviso poderá conter
informações importantes a respeito de sua aplicação ou cobertura por meio Tiếng Việt (Vietnamese):
do Premera Blue Cross. Poderão existir datas importantes neste aviso. Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông
Talvez seja necessário que você tome providências dentro de tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua
determinados prazos para manter sua cobertura de saúde ou ajuda de chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông
custos. Você tem o direito de obter esta informação e ajuda em seu idioma báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn
e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357). để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có
quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình
miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).You can also read
