Opioid Risk Management
Indications for Prior Authorization
Criteria
Short-Acting Opioids
Note: Patients with a cancer drug in their prescription claims history within the previous 365 days will not be subject to a max daily dose, day supply, or fill restriction. Additionally, if criteria is approved patients will not be subject to a max daily dose, day supply, or fill restriction.
Quantity Limit
Length of Approval: 12 Month(s)
For diagnosis of Cancer or end-of-life care
- Diagnosis of cancer or end of life care
Short-Acting Opioids
*Patients with a cancer drug in their prescription claims history within the previous 365 days will not be subject to a max daily dose, day supply, or fill restriction. Additionally, if criteria is approved patients will not be subject to a max daily dose, day supply, or fill restriction.
Quantity Limit
Length of Approval: 14 Day(s)
For diagnosis of Postoperative Pain Management
- Medication is being used to treat postoperative pain AND
- Medication is not being prescribed for pain related to a dental procedure AND
- The dose being prescribed is the dose that the patient was stable on prior to discharge
Short-Acting Opioids
Note: Patients with a cancer drug in their prescription claims history within the previous 365 days will not be subject to a max daily dose, day supply, or fill restriction. Additionally, if criteria is approved patients will not be subject to a max daily dose, day supply, or fill restriction. If the prescriber is unable to certify written documentation to meet criterion (2) and/or (3), written or verbal attestation from the provider may be accepted confirming that the prescriber (or prescriber’s representative) has verbally addressed criterion (2) and/or (3) with the patient.
Quantity Limit
Length of Approval: 6 Month(s)
For diagnosis of All Other Diagnoses
- Prescriber certifies that there is an active treatment plan that includes but is not limited to a specific treatment objective and the use of other pharmacological and non-pharmacological agents for pain relief as appropriate AND
- Prescriber certifies that there has been an informed consent document signed and an addiction risk assessment has been performed AND
- Prescriber certifies that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists
Opioid Cough Medications
Prior Authorization
Length of Approval: 6 Month(s)
- Patient is 18 years of age or older
Opioid Cough Medications*
*This guideline only applies in the absence of a drug-specific quantity limit override guideline. No override requests will be permitted for acetaminophen, alone or in combination with other agents, which will exceed a total of 4 grams of acetaminophen per day. **NOTE: Published biomedical literature may be used as evidence to support safety and additional efficacy at higher than maximum doses for the diagnosis provided.
Quantity Limit
Length of Approval: 60 Day(s)
For diagnosis of Greater than the maximum dose as specified in the product prescribing information OR compendia for off-label uses (in the absence of a drug-specific guideline)*
- One of the following:
- Quantity limit override requests must involve an FDA-approved indication OR
- Quantity limit override requests involving off-label indications must meet off-label guideline approval criteria
- One of the following:
- The maximum doses specified under the quantity restriction have been tried for an adequate period of time and been deemed ineffective in the treatment of the member's disease or medical condition OR
- If lower doses have not been tried, there is clinical support (i.e., clinical literature, patient attributes, or characteristics of the drug) that the number of doses available under the quantity restriction will be ineffective in the treatment of the member's disease or medical condition
- One of the following:**
- Higher dose or quantity is supported in the dosage and administration section of the manufacturer's prescribing information OR
- Higher dose or quantity is supported by one of following compendia:
- American Hospital Formulary Service Drug Information
- Micromedex DRUGDEX System
Long Acting Opioids: Nucynta ER
If the member does not meet the medical necessity reauthorization authorization criteria requirements, a denial should be issued and a maximum 30-day authorization may be authorized one time for the requested drug/strength combination up to the requested quantity and/or MME for transition to an alternative treatment.
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Cancer or End-of-Life Care
- One of the following:
- Diagnosis of cancer OR
- Patient is receiving opioids as part of end-of-life care
- Trial and failure, contraindication or intolerance to at least two of the following preferred products
- Hydromorphone ER
- Morphine sulfate ER
- Oxymorphone ER
- Hysingla ER
- Oxycontin
- Xtampza ER
Long Acting Opioids: Nucynta ER
If the member does not meet the medical necessity reauthorization authorization criteria requirements, a denial should be issued and a maximum 30-day authorization may be authorized one time for the requested drug/strength combination up to the requested quantity and/or MME for transition to an alternative treatment.
Prior Authorization (Initial Authorization)
Length of Approval: 6 Month(s)
For diagnosis of Non-Cancer/End-of-Life Care Diagnosis
- One of the following:
- All of the following:
- Patient has moderate to severe chronic pain that is non-neuropathic AND
- One of the following:
- For patients that are filling the prescribed medication for the first time, prior to the start of therapy with the prescribed medication, the patient has failed an adequate (minimum 4 week) trial of a short-acting opioid [Document drug(s), dose, duration and date of trial] OR
- Patient is established on the prescribed medication and this prescription is for continuation of therapy
- All of the following:
- Patient has moderate to severe neuropathic pain or fibromyalgia AND
- Unless contraindicated, the patient has not exhibited an adequate response to 8 weeks of treatment with gabapentin titrated to a therapeutic dose (Document drug(s), dose, duration and date of trial) AND
- Unless contraindicated, the patient has not exhibited an adequate response to at least 6-8 weeks of treatment with a tricyclic antidepressant (e.g., amitriptyline, nortriptyline, imipramine) titrated to a therapeutic dose (Document drug(s), dose, duration and date of trial) AND
- One of the following:
- For patients that are filling the prescribed medication for the first time, prior to the start of therapy with the prescribed medication, the patient has failed an adequate (minimum 4 week) trial of a short-acting opioid [Document drug(s), dose, duration and date of trial] OR
- Patient is established on the prescribed medication and this prescription is for continuation of therapy
- None of the following:
- For use as an as-needed PRN analgesic
- For pain that is mild or not expected to persist for an extended period of time
- For acute pain
- For postoperative pain, unless the patient is already receiving chronic opioid therapy prior to surgery, or if postoperative pain is expected to be moderate to severe and persist for an extended period of time
- Trial and failure, contraindication or intolerance to at least two of the following preferred products
- Hydromorphone ER
- Morphine sulfate ER
- Oxymorphone ER
- Hysingla ER
- Oxycontin
- Xtampza ER
Long Acting Opioids: Nucynta ER
If the member does not meet the medical necessity reauthorization authorization criteria requirements, a denial should be issued and a maximum 30-day authorization may be authorized one time for the requested drug/strength combination up to the requested quantity and/or MME for transition to an alternative treatment.
Prior Authorization (Reauthorization)
Length of Approval: 6 Month(s)
For diagnosis of Non-Cancer/End-of-Life Care Diagnosis
- Documentation has been provided addressing ALL of the following
- Treatment goals are defined, including estimated duration of treatment
- Treatment plan includes the use of a nonopioid analgesic and/or nonpharmacologic intervention
- Patient demonstrates meaningful improvement in pain and function using a validated instrument (e.g., Brief Pain Inventory)
- Patient has been screened for substance abuse/opioid dependence using a validated instrument (e.g., DAST-10)
- Rationale for not tapering and discontinuing
- Patient has been screened for comorbid mental health
- If a state prescription drug monitoring program (PDMP) is available, the prescriber has identified there are no concurrently prescribed controlled substances from PDMP
- If used in patients with medical comorbidities or if used concurrently with a benzodiazepine or other drugs that could potentially cause drug-drug interactions, the prescriber has acknowledged that they have completed an assessment of increased risk for respiratory depression
- Total daily morphine equivalent dose
Long Acting Opioids: generic transdermal fentanyl patches, generic methadone 5 mg tablets, generic methadone 10 mg tablets, brand MS CONTIN, generic morphine sulfate ER, generic oxymorphone ER, Brand HYSINGLA ER, OXYCONTIN, generic oxycodone ER, Xtampza ER, generic hydrocodone ER, Generic Morphine Sulfate ER, generic hydromorphone ER
If the member is currently taking the requested long-acting opioid OR was recently switched from another long-acting opioid and does not meet the medical necessity initial authorization criteria requirements, a denial should be issued and a maximum 30-day authorization may be authorized one time for the requested drug/strength combination up to the requested quantity and/or MME for transition to an alternative treatment.
Prior Authorization (Initial Authorization)
Length of Approval: 6 Month(s)
For diagnosis of Non-Cancer/End of Life Care Diagnosis
- One of the following:
- All of the following:
- Patient has moderate to severe chronic pain that is non-neuropathic AND
- One of the following:
- For patients that are filling the prescribed medication for the first time, prior to the start of therapy with the prescribed medication, the patient has failed an adequate (minimum 4 week) trial of a short-acting opioid [Document drug(s), dose, duration and date of trial] OR
- Patient is established on the prescribed medication and this prescription is for continuation of therapy
- All of the following:
- Patient has moderate to severe neuropathic pain or fibromyalgia AND
- Unless contraindicated, the patient has not exhibited an adequate response to 8 weeks of treatment with gabapentin titrated to a therapeutic dose (Document drug(s), dose, duration and date of trial) AND
- Unless contraindicated, the patient has not exhibited an adequate response to at least 6-8 weeks of treatment with a tricyclic antidepressant (e.g., amitriptyline, nortriptyline, imipramine) titrated to a therapeutic dose (Document drug(s), dose, duration and date of trial) AND
- One of the following:
- For patients that are filling the prescribed medication for the first time, prior to the start of therapy with the prescribed medication, the patient has failed an adequate (minimum 4 week) trial of a short-acting opioid [Document drug(s), dose, duration and date of trial] OR
- Patient is established on the prescribed medication and this prescription is for continuation of therapy
- None of the following:
- For use as an as-needed PRN analgesic
- For pain that is mild or not expected to persist for an extended period of time
- For acute pain
- For postoperative pain, unless the patient is already receiving chronic opioid therapy prior to surgery, or if postoperative pain is expected to be moderate to severe and persist for an extended period of time
Long Acting Opioids: generic transdermal fentanyl patches, generic methadone 5 mg tablets, generic methadone 10 mg tablets, brand MS CONTIN, generic morphine sulfate ER, generic oxymorphone ER, Brand HYSINGLA ER, OXYCONTIN, generic oxycodone ER, Xtampza ER, generic hydrocodone ER, Generic Morphine Sulfate ER, generic hydromorphone ER
If the member does not meet the medical necessity reauthorization criteria requirements, a denial should be issued and a maximum 30-day authorization may be authorized one time for the requested drug/strength combination up to the requested quantity and/or MME for transition to an alternative treatment.
Prior Authorization (Reauthorization)
Length of Approval: 6 Month(s)
For diagnosis of Non-Cancer/End-of-Life Care Diagnosis
- Documentation has been provided addressing ALL of the following:
- Treatment goals are defined, including estimated duration of treatment
- Treatment plan includes the use of a nonopioid analgesic and/or nonpharmacologic intervention
- Patient demonstrates meaningful improvement in pain and function using a validated instrument (e.g. Brief Pain Inventory)
- Patient has been screened for substance abuse/opioid dependence using a validated instrument (e.g. DAST-10)
- Rationale for not tapering and discontinuing opioid
- Patient has been screened for comorbid mental health conditions
- If a state prescription drug monitoring program (PDMP) is available, the prescriber has identified there are no concurrently prescribed controlled substances from PDMP
- If used in patients with medical comorbidities or if used concurrently with a benzodiazepine or other drugs that could potentially cause drug-drug interactions, the prescriber has acknowledged that they have completed an assessment of increased risk for respiratory depression
- Total daily morphine equivalent dose
Long Acting Opioids: generic transdermal fentanyl patches, generic methadone 5 mg tablets, generic methadone 10 mg tablets, brand MS CONTIN, generic morphine sulfate ER, generic oxymorphone ER, Brand HYSINGLA ER, OXYCONTIN, generic oxycodone ER, Xtampza ER, generic hydrocodone ER, Generic Morphine Sulfate ER, generic hydromorphone ER
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Cancer or End-of-Life Care
- One of the following:
- Diagnosis of cancer OR
- Patient is receiving opioids as part of end-of-life care
Brand Butrans, generic buprenorphine patch, Brand Belbuca*, Generic buprenorphine buccal
*Prior authorization may not apply depending on the plan
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Cancer or End-of-Life Care
- Patient is being treated for cancer related pain or pain associated with end-of-life
Brand Butrans, generic buprenorphine patch, Brand Belbuca*, Generic buprenorphine buccal
*Prior authorization may not apply depending on the plan. If the member is currently taking the requested long-acting opioid OR was recently switched from another long-acting opioid and does not meet the medical necessity initial authorization criteria requirements, a denial should be issued and a maximum 30-day authorization may be authorized one time for the requested drug/strength combination up to the requested quantity and/or MME for transition to an alternative treatment.
Prior Authorization (Initial Authorization)
Length of Approval: 6 Month(s)
For diagnosis of Non- Cancer Pain
- The patient is being treated for pain severe enough to require daily, around-the-clock, longer-term opioid treatment AND
- None of the following:
- For use as an as-needed PRN analgesic
- For pain that is mild or not expected to persist for an extended period of time
- For acute pain
- For opioid dependence
- The patient is not receiving other long-acting opioids concurrently
Brand Butrans, generic buprenorphine patch, Brand Belbuca*, Generic buprenorphine buccal
*Prior authorization may not apply depending on the plan. If the member does not meet the medical necessity reauthorization authorization criteria requirements, a denial should be issued and a maximum 30-day authorization may be authorized one time for the requested drug/strength combination up to the requested quantity and/or MME for transition to an alternative treatment.
Prior Authorization (Reauthorization)
Length of Approval: 6 Month(s)
For diagnosis of Non-Cancer Pain
- Documentation has been provided addressing ALL of the following
- Treatment goals are defined, including estimated duration of treatment
- Treatment plan includes the use of a nonopioid analgesic and/or nonpharmacologic intervention
- Patient demonstrates meaningful improvement in pain and function using a validated instrument (e.g. Brief Pain Inventory)
- Patient has been screened for substance abuse/opioid dependence using a validated instrument (e.g. DAST-10)
- Rationale for not tapering and discontinuing opioid
- Patient has been screened for comorbid mental health conditions
- If a state prescription drug monitoring program (PDMP) is available, the prescriber has identified there are no concurrently prescribed controlled substances from PDMP
- If used in patients with medical comorbidities or if used concurrently with a benzodiazepine or other drugs that could potentially cause drug-drug interactions, the prescriber has acknowledged that they have completed an assessment of increased risk for respiratory depression
- Total daily morphine equivalent dose
P & T Revisions
2024-11-06, 2024-10-28, 2024-01-30, 2023-12-05, 2023-10-19, 2023-08-30, 2023-08-26, 2023-07-14, 2023-05-22, 2022-12-08, 2022-11-18, 2022-07-05, 2022-04-19, 2022-02-21, 2021-11-09, 2021-09-03, 2021-07-16, 2021-04-05, 2021-04-01, 2021-03-03, 2020-12-01, 2020-10-16, 2020-10-01, 2020-07-14, 2020-04-02, 2020-03-10, 2019-10-02
References
- Zohydro ER Prescribing Information.Currax Pharmaceuticals LLC. October 2019.
Revision History
- 2024-11-06: update guideline
- 2024-10-28: update guideline
- 2024-01-30: update guideline
- 2023-12-05: update guideline
- 2023-10-19: Annual review
- 2023-08-30: Update Program
- 2023-08-26: Update program
- 2023-07-14: Update Program
- 2023-05-22: Removed inactive products
- 2022-12-08: Annual Review
- 2022-11-18: Annual Review
- 2022-07-05: Addition of new Roxybond formulations.
- 2022-04-19: GPI Reclassification
- 2022-02-21: Update guideline
- 2021-11-09: Updated guideline
- 2021-09-03: Added generic buprenorphine buccal film.
- 2021-07-16: Update to Post-op Pain notes
- 2021-04-05: Added generic Hysingla ER
- 2021-04-01: Added Prolate Solution
- 2021-03-03: Updated Long Acting Opioid criteria.
- 2020-12-01: Added Qdolo as a target drug to short acting opioid QL overrride section of ORM Guideline
- 2020-10-16: 2020 UM Annual Review. GPI replication updates.
- 2020-10-01: Per instruction, add Xtampza ER as a preferred option within the non-preferred long-acting criteria sections (i.e., Opana ER, Arymo ER, brand Kadian, Morphabond ER, Nucynta ER, Brand Zohydro ER).
- 2020-07-14: Changed Xtampza ER to preferred product and added generic hydrocodone ER.
- 2020-04-02: Added Prolate
- 2020-03-10: Add generic hydrocodone ER
- 2019-10-02: 2019 Annual Review
HEALTHY LIVING