Opioid Coverage Limit (initial seven-day supply)

Opioid Coverage Limit (initial seven-day supply)

Description:

Initial prescription coverage of an opioid medication is provided by Western Health Advantage (WHA) for up to a seven-day supply without the need for prior authorization.  According to the CDC Guideline for Prescribing Opioids (2016), “When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.”  WHA's seven-day opioid supply limit applies to members who have not filled an opioid prescription using their WHA pharmacy benefit in the previous 120 days.

Diagnosis considered for coverage:

Initial management of moderate to severe acute pain or chronic pain that requires more than a seven (7)-day supply of an opioid medication.

For diagnosis of pain associated with cancer, sickle cell disease, or end-of-life care

• Documentation confirms a diagnosis of pain associated with current cancer, sickle cell disease, or end-of-life care.

For diagnosis of postsurgical pain

• Medication is being used to treat postoperative pain with expected longer-term recovery (e.g., lumbar fusion, knee replacement, hip replacement, abdominal hysterectomy, axillary lymph node resection, etc.); AND
• Medication is not being prescribed for pain related to a dental procedure

For diagnosis of acute OR chronic pain conditions

• One of the following:
  • Patient is established on the prescribed medication and the request is for continuation of therapy
  • Documentation includes a medically necessary reason to exceed an initial seven-day supply; AND
• Medical records document a current diagnosis of pain with a patient-specific treatment plan for evaluating pain level, functional performance, diversion risk, and monitoring of side effects; AND
• Patient has experienced an inadequate response or intolerable side effects to non-narcotic analgesics (e.g. NSAIDs, acetaminophen, anticonvulsants, antidepressants, topical agents, etc.); AND
• The quantity requested does not exceed what is medically necessary to adequately treat pain.

Coverage Duration:

1 month

Review History:

05/17/2022 - Medical necessity criteria approved by P&T for WHA's seven-day opioid supply limit.

References:

1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. Jama. 2016 Apr 19;315(15):1624-45.