Pharmacy Policy Bulletin

Opioid Management - Commercial

Number: J-0672

Category: Prior Authorization

Line(s) of Business:

Commercial
Healthcare Reform
Medicare

Benefit(s):

Commercial Plans (1., 2., or 3.)

Rx Mgmt Performance = Deterrent/Patent Extenders
Rx Mgmt Performance = Deterrent/Patent Extenders + Guideline
Rx Mgmt Performance = MRXC = Yes

Region(s):

All
Delaware
New York
Pennsylvania
West Virginia

Additional Restriction(s):

None

Approval Criteria

Short‐acting opioid analgesics

When a benefit, short‐acting opioid analgesics for greater than 7 days’ supply per fill and greater than 14 days’ supply per 30 days may be approved for the following: (A or B or C):

A. Documentation of pain associated with (1 or 2 or 3):

1. Active cancer treatment or cancer not in remission (provide diagnosis)

2. Hospice program, end-of-life care, or palliative care

3. Sickle cell anemia

B. Individual is currently utilizing opioid therapy on a consistent basis for chronic pain (Individuals currently receiving opioids on a consistent basis is defined as prescribed use for 90 out of the past 110 days)

C. Documentation being used for the treatment of severe pain and all the following criteria (1,2 and 3)

1. Non-opioid therapies (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen) have provided an inadequate response or are inappropriate according to the prescribing physician; AND

2. The patient’s history of controlled substance prescriptions has been checked using the state prescription drug monitoring program (PDMP) according to the prescribing physician; AND

3. Documentation the member, or parent/guardian, has been educated on the potential adverse effects of opioid analgesics, including the risk of misuse, abuse, and addiction.

Extended release opioids

When a benefit, extended release opioid may be approved for the following: (A or B):

A. Documentation of pain associated with (1 or 2 or 3):

1. Active cancer treatment or cancer not in remission (provide diagnosis)

2. Hospice program, end-of-life care, or palliative care

3. Sickle cell anemia

B. Documentation of all the following (1,2,3, 4 and 5)

1. Pain is severe enough to require daily, around-the-clock, long-term opioid treatment

2. Patient is not opioid naïve;

3. At least one of the following therapies have been evaluated

a. Non-opioid therapies (e.g., non-opioid medications [e.g., nonsteroidal anti-inflammatory drugs {NSAIDs}, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors {SNRIs}, anticonvulsants]

b. Exercise therapy

c. Physical therapy

d. Weight loss

e. Cognitive behavioral therapy

4. The patient’s history of controlled substance prescriptions has been checked using the state prescription drug monitoring program (PDMP), according to the prescribing physician

5. Documentation the member, or parent/guardian, has been educated on the potential adverse effects of opioid analgesics, including the risk of misuse, abuse, and addiction.

Morphine Equivalent Daily Dose (MEqD)

When a benefit, cumulative opioids that exceeded 90 MEqD be approved for the following: (A. or B)

A. Documentation of pain associated with (1 or 2 or 3):

1. Active cancer treatment or cancer not in remission (provide diagnosis)

2. Hospice program, end-of-life care, or palliative care

3. Sickle cell anemia

B. The prescriber states based on the patient’s clinical circumstances that the amount of opioid prescribed is warranted in order to adequately manage the patient’s pain

Limitations of Coverage

I. Coverage of opioids for disease states outside of their FDA-approved indications should be denied based on the lack of clinical data to support their effectiveness and safety in other conditions.

Authorization Duration

Commercial Plans: If approved, up to a 6 month authorization may be granted base on patient treatment plan for Short‐acting opioid analgesics and extended release opioids.
Commercial Plans: If approved, up to a 12 month authorization may be granted base on patient treatment plan for Morphine Equivalent Daily Dose

Automatic Approval Criteria

None