Blue Cross Community CentennialSM: Opioid Diagnosis Code Required at Pharmacy

September 19, 2019

Effective Nov. 1, 2019: Each opioid prescription for Blue Cross Community Centennial members will be required to have a valid and appropriate diagnosis (defined below) in order for Blue Cross and blue Shield of New Mexico (BCBSNM) to provide coverage for the opioid prescription. Excluded from this requirement, will be buprenorphine products used for treating opioid addiction.

  • Valid Code: Current ICD10 diagnosis codes can be found in the CMS coding database Learn more about third-party links
  • Appropriate Code: A Valid ICD10 Diagnosis (Dx) code that is an appropriate indication for the use of opioids. (i.e. G89.3 Neoplasm related pain)

The purpose of this update is to notify our valued medical providers about a new program that will be implemented in our work on the opioid epidemic in our communities. Our teams have implemented many standard opioid safety edits to limit the opioids available to the public to medically necessary purposes only and to prevent diversion and inappropriate use.

To further ensure proper utilization of opioids we have worked closely with our Pharmacy Benefit Manager, Prime Therapeutics, to build and implement a Dx code requirement at the dispensing Pharmacy. The benefits of this will be to have faster and improved care management and disease management engagement with our members. This new process will ensure that all opioid prescriptions covered for our members are appropriate and that the dispensing pharmacists are aware of the patient’s pain treatment needs.

For questions about drug coverage, plan members can call the Customer Service number on their member ID card.

Such services are funded in part with the State of New Mexico.