Pharmacy Prior Authorization Criteria

Opioid Quantity Limit Overrides

Indications for Prior Authorization

Criteria

Authorization will be issued for long-term therapy. *For oral fentanyl products, please refer to the drug-specific quantity limit override criteria in the “Oral Fentanyl Products” guideline.

Administrative

Length of Approval: 5 Year(s)
For diagnosis of For Malignant Cancer Pain

• In the absence of an opioid-specific quantity limit override guideline, the following approval criteria will be used:
• Diagnosis of malignant (cancer) pain*

Administrative

Length of Approval: 1 Year(s)
For diagnosis of For Non-Malignant Pain

• In the absence of an opioid-specific quantity limit override guideline, the following approval criteria will be used:
• Prescribed by a pain specialist or by pain management consultation
AND
• The prescriber maintains and provides chart documentation of the patient’s evaluation, including all of the following:
• An appropriate patient medical history and physical examination
• A description of the nature and intensity of the pain
• Documentation of appropriate dose escalation
• Documentation of ongoing, periodic review of the course of opioid therapy
• An updated, comprehensive treatment plan (the treatment plan should state objectives that will be used to determine treatment success, such as pain relief or improved physical and/or psychosocial function)
• Verification that the risks and benefits of the use of the controlled substance have been discussed with the patient, significant other(s), and/or guardian

P & T Revisions

2024-11-06, 2023-10-19, 2022-10-19, 2022-01-14, 2021-10-28, 2021-09-28, 2021-05-21, 2020-10-29, 2019-10-29

References

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Revision History

• 2024-11-06: 2024 Annual Review. No criteria changes.
• 2023-10-19: Annual review
• 2022-10-19: Annual review
• 2022-01-14: Annual Review
• 2021-10-28: Annual Review
• 2021-09-28: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2020-10-29: UM annual review.
• 2019-10-29: 2019 Annual Review

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