CurrentAdvanced HealthPolicy N/A

Opioid Drug Use Policy for Chronic Non-Malignant Pain and Acute Opioid Prescriptions Exceeding SUPPORT ACT Safety Edits

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This policy governs coverage, prior authorization, quantity limits, safety edits, and documentation requirements for chronic opioid therapy and acute opioid prescriptions that exceed SUPPORT Act safety thresholds. It applies to opioid prescriptions covered by Advanced Health, with explicit exemptions for hospice, palliative care, cancer treatment, certain long-term care residents, and sickle cell disease.

Policy Summary

PayerAdvanced Health

PolicyOpioid Drug Use Policy for Chronic Non-Malignant Pain and Acute Opioid Prescriptions Exceeding SUPPORT ACT Safety Edits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewAug 1, 2024

Next Review DateN/A

Key ActionDocument or attest that the Prescription Drug Monitoring Program was queried for every opioid prescription submitted for coverage consideration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MEDHard threshold for new short-acting opioid starts

50 MEDSoft threshold for new short-acting opioid starts

7 daysNew short-acting opioid supply limit

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CurrentAdvanced HealthPolicy N/A

Opioid Drug Use Policy for Chronic Non-Malignant Pain and Acute Opioid Prescriptions Exceeding SUPPORT ACT Safety Edits

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Sign up for all advancedhealth policy alerts

Know when advancedhealth releases new policies or updates existing guidance.

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Policy Summary

PayerAdvanced Health

PolicyOpioid Drug Use Policy for Chronic Non-Malignant Pain and Acute Opioid Prescriptions Exceeding SUPPORT ACT Safety Edits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewAug 1, 2024

Next Review DateN/A

Key ActionDocument or attest that the Prescription Drug Monitoring Program was queried for every opioid prescription submitted for coverage consideration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MEDHard threshold for new short-acting opioid starts

50 MEDSoft threshold for new short-acting opioid starts

7 daysNew short-acting opioid supply limit

Post-operative coverage period

85%Opioid refill threshold

60/180 daysChronic opioid use definition

Coverage Criteria

Chronic Opioid Therapy

Chronic opioid therapy is covered when the applicable drug use criteria are met and required documentation is submitted.

ALL of the following

The patient is receiving opioid pain medication for chronic use that meets the plan's drug use criteria.
Required opioid coverage documentation is submitted, including PDMP query attestation as applicable.

Unsupported New-Start Conditions

New-start long-term opioid therapy is not a covered benefit for painful conditions determined by the CDC or another regulatory entity to be ineffective or insufficiently supported for improving pain or function with long-term opioid use.

ANY of the following unsupported new-start conditions

Low back pain
Headache, including migraine headache
Fibromyalgia
Temporomandibular joint (TMJ) pain
Pelvic pain syndrome
Neuropathy

Concurrent Opioid Therapy

The following concurrent opioid combinations are not covered because of safety concerns, insufficient safety evidence, or the potential for dose escalation.

ANY of the following combinations

Two short-acting opioids used concurrently are not covered.
A long-acting opioid used concurrently with a short-acting opioid is not covered.

High-Dose Exception and MED Thresholds

Dose thresholds apply to new starts of short-acting opioids. Exceptions above the soft threshold may be considered through prior authorization when the required risk screening and clinical documentation are completed.

Applicable dose limits and exception requirements

A 90 MED-per-day limit applies to new starts of short-acting opioids at the point of sale as a hard threshold.
Exceptions may be requested through prior authorization when the required risk screening has been performed and the Oregon Prescription Drug Monitoring Program has been reviewed.
A 50 MED-per-day soft threshold applies to new starts of short-acting opioids.
The soft threshold may be overridden by the pharmacy when the appropriate DUR code is submitted.
For doses greater than 50 MED per day, appropriate patient risk screening must be performed, including the annual SBIRT questionnaire, AUDIT, and DAST.
A urine drug screen must be submitted for consideration of the exception.

Post-Operative Opioid Therapy

Post-operative opioid coverage is subject to duration, supply, refill, and ongoing-use documentation limits.

ALL applicable post-operative limits

Post-operative pain medication is allowed for up to 14 days following the surgery date.<= 14 days
New starts of short-acting opioids are limited to a 7-day supply.<= 7-day supply
A refill threshold of 85% applies, consistent with the general refill threshold for controlled and non-controlled substances.85%
Justification for ongoing opioid use beyond 14 days is required.

Extended-Release Opioids

All extended-release opioid prescriptions require prior authorization.

ALL of the following

Prior authorization is obtained for the extended-release opioid prescription.
This requirement applies to all extended-release opioid prescriptions.
For pain related to the back or spine, the elements of Guideline Note 60—Opioids for Conditions of the Back and Spine—of the Prioritized List of Health Services are also met.

PDMP Review Documentation

Coverage consideration for any opioid medication requires documentation that the Prescription Drug Monitoring Program was queried.

ALL of the following

The provider queries the Prescription Drug Monitoring Program (PDMP).
The provider submits an attestation that the PDMP check was completed.

Individuals receiving hospice care, palliative care, or cancer treatment are exempt from these requirements. Residents of long-term care facilities described in 42 USC 1396a(oo)(3)(A)(ii) and individuals with sickle cell disease are also exempt.

Examples include low back pain, headache including migraine headache, fibromyalgia, TMJ, pelvic pain syndrome, and neuropathy.

Two short-acting opioids will not be covered concurrently because of safety concerns. A combination of a long-acting opioid and a short-acting opioid is also not covered because of insufficient safety evidence and the potential for dose escalation.

Thresholds and Coverage Parameters

Prior Authorization and Documentation Actions

Prior Authorization

Extended-Release Opioid Prior Authorization

Prior authorization is required for all extended-release opioid prescriptions. Requests for pain related to the back or spine must also meet the applicable elements of Guideline Note 60: Opioids for Conditions of the Back and Spine, from the Prioritized List of Health Services.

Prior Authorization

High-Dose Opioid Exception

Doses above the applicable MED thresholds may be considered only through the exception or prior authorization process when required risk screening, Oregon PDMP review, and functional treatment goals are documented and submitted.

>50 MED/day: complete the required annual risk screening, submit a urine drug screen, review the Oregon PDMP for inconsistencies or aberrancies, and establish functional treatment goals.
>90 MED/day: obtain an exception or prior authorization after the required risk screening and Oregon PDMP review are completed.

Unsupported block type: documentation

Policy Background

This policy addresses the risks associated with opioid pain medications, including adverse drug events, diversion, misuse, and unsafe dose escalation. It promotes evidence-based prescribing and incorporates safety considerations for acute and chronic opioid therapy.

Definitions

Initial Therapy Criteria

New Opioid Start

New opioid therapy is subject to safety thresholds, supply limits, indication restrictions, and PDMP documentation.

Initial opioid therapy

Safety thresholds
- A new short-acting opioid start does not exceed the 90 MED hard threshold applied at point of sale.90 MED
- A new short-acting opioid start complies with the 50 MED soft threshold, unless overridden by an appropriate pharmacy-submitted DUR code or addressed through prior authorization.50 MED/day
Supply limit: The new short-acting opioid prescription does not exceed a 7-day supply.

Continuation Criteria

Chronic Opioid Continuation

Continuation of chronic opioid therapy may be covered when the applicable drug use criteria and documentation requirements are met.

Continuation requirements

The patient meets the applicable drug use criteria.
The provider documents or attests that the Prescription Drug Monitoring Program was queried.

Tapering

Tapering is not required when the provider attests that tapering is currently unsafe.

Taper exception: The provider attests that tapering is currently unsafe.

No maximum timeframe is enforced for opioid tapers.

Quantity and Refill Limits

Policy Summary

PayerAdvanced Health

PolicyOpioid Drug Use Policy for Chronic Non-Malignant Pain and Acute Opioid Prescriptions Exceeding SUPPORT ACT Safety Edits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewAug 1, 2024

Next Review DateN/A

Key ActionDocument or attest that the Prescription Drug Monitoring Program was queried for every opioid prescription submitted for coverage consideration.

SourceLink

On This Page

The provider must review the Oregon Prescription Drug Monitoring tool for inconsistencies or aberrancies.

Functional treatment goals must be established and submitted with the prior authorization request.

Documentation Required

High-Dose Risk Documentation

For opioid doses above 50 MED per day, submit annual risk-screening and monitoring documentation with the prior authorization request.

Annual SBIRT questionnaire
Annual AUDIT screening
Annual DAST screening
Urine drug screen
Provider review of the Oregon Prescription Drug Monitoring tool for inconsistencies or aberrancies
Established functional treatment goals

Prior Authorization

Justification for Extended Post-Operative Use

Post-operative opioid coverage is allowed for up to 14 days following the surgery date. Provide clinical justification for continued opioid use beyond 14 days.

The CDC guideline recommends post-operative opioid use for less than 7 days.
New starts of short-acting opioids are limited to a 7-day supply.
A refill threshold of 85% applies.

Documentation Required

Taper Safety Attestation

An opioid taper is not required when the provider attests that tapering is currently unsafe. No maximum timeframe is enforced for opioid tapers.

Document the provider attestation that tapering is currently unsafe.
Refer to the Oregon Pain Guidance Tapering Flow Chart when clinically appropriate.

Denial Risk

Unsupported New-Start Indication

New-start opioid use is not a covered benefit for painful conditions that the CDC or another regulatory entity has determined to be ineffective for, or to have insufficient evidence supporting, improved pain or function with long-term opioid use.

Examples include low back pain, headache including migraine headache, fibromyalgia, temporomandibular joint pain, pelvic pain syndrome, and neuropathy.

Denial Risk

Unsafe Opioid Combinations

Concurrent use of two short-acting opioids is not covered because of safety concerns. The combination of a long-acting opioid with a short-acting opioid is also not covered because of insufficient safety evidence and the potential for dose escalation.

Avoid concurrent short-acting opioid therapy.
Avoid combining long-acting and short-acting opioids unless coverage requirements are otherwise satisfied.

Prior Authorization

MED Threshold Exceedance

A 90 MED limit for new starts of short-acting opioids is applied at the point of sale as a hard threshold. Exceptions may be requested through prior authorization when the required risk screening has been performed and the Oregon PDMP has been reviewed.

A 50 MED soft threshold also applies to new starts of short-acting opioids and may be overridden by the pharmacy submitting the appropriate DUR code.

Denial Risk

Missing Extended-Release Opioid Authorization

Prescriptions for extended-release opioids will be denied or may not be considered for coverage when the required prior authorization and supporting criteria are missing.

Submit the prior authorization before dispensing.
For back- or spine-related pain, include documentation that the applicable Guideline Note 60 requirements are met.

Denial Risk

No PDMP Documentation

Coverage consideration may be denied when documentation that the PDMP was queried is absent. A provider attestation confirming the PDMP check is required for every opioid prescription.

Ensure the PDMP query documentation or attestation accompanies the request.

Prior Authorization

Post-Operative Duration or Supply Exceedance

Coverage beyond the post-operative duration or supply limits requires supporting justification. Post-operative opioid coverage is generally limited to 14 days after surgery, and new starts of short-acting opioids are limited to a 7-day supply.

Document justification for opioid use beyond 14 days after surgery.
Apply the 85% refill threshold consistent with other controlled and non-controlled substances.

Indication restrictions: The opioid is not being newly started for a condition for which the CDC or another regulatory entity has determined that long-term opioid use is ineffective or lacks sufficient evidence to support improved pain or function.

PDMP documentation: The provider documents or attests that the Prescription Drug Monitoring Program was queried.

Extended-Release Opioid Initiation

Extended-release opioid initiation requires prior authorization.

Extended-release initiation: Prior authorization is obtained for the extended-release opioid prescription before coverage consideration.

Requests for pain related to the back or spine must also meet Guideline Note 60, Opioids for Conditions of the Back and Spine, from the Prioritized List of Health Services.