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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAdvanced Health Opioid Prior Auth | OpenPayer
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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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    This policy governs coverage, prior authorization, safety edits, quantity limits, and tapering requirements for chronic opioid therapy and acute opioid prescriptions that exceed SUPPORT Act safety thresholds. It applies to providers prescribing opioids for eligible Oregon Health Plan-funded conditions, subject to stated exclusions and exceptions.

    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 ReviewDec 1, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization for all extended-release opioid prescriptions.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    50 MED/dayNew chronic therapy maximum
    90 MED/dayAcute hard threshold
    14 daysPost-operative coverage
    7 days

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    New short-acting supply
    85%Refill threshold
    90 daysStandard taper period

    Coverage Criteria

    Chronic Opioid Therapy

    Chronic opioid therapy is covered when all applicable requirements are met.

    Chronic opioid coverage: The patient has a condition funded for coverage by the Oregon Health Plan; chart notes and a physical examination support the funded diagnosis; the condition is not one for which long-term opioids are considered ineffective or insufficiently supported; the patient is not currently using alcohol or illegal substances; prohibited opioid combinations and prohibited opioid-drug combinations are absent or are being tapered under an approved plan; and the dose is at or below 50 mg MED/day for a new chronic start.50 mg MED/day for new chronic starts

    Patients already above 50 MED/day may qualify for a taper or an approved high-dose exception.

    Opioid Dose Above 50 MED/day

    Coverage above 50 MED/day may be considered when all exception requirements are met.

    High-dose exception: The provider performs an annual SBIRT questionnaire, AUDIT and DAST risk screening; submits a urine drug screen; reviews the Oregon Prescription Drug Monitoring tool for inconsistencies or aberrancies; and establishes and submits functional treatment goals with the prior authorization request.>50 MED/day

    Approval remains subject to prior authorization review.

    Acute and Post-Operative Opioids

    Acute post-operative opioid coverage is limited by duration, supply, refill, and dose safety edits.

    Acute and post-operative opioid coverage: Post-operative opioid treatment is within 14 days after surgery; a new short-acting opioid start does not exceed a 7-day supply; the 85% refill threshold is met; the new short-acting opioid dose does not exceed the 90 MED/day hard threshold unless an exception is authorized; and the 50 MED/day soft threshold is addressed through an appropriate pharmacy DUR code when applicable.14 days post-surgery; 7-day new-start supply; 90 MED/day hard threshold; 50 MED/day soft threshold; 85% refill threshold

    Justification is required for ongoing post-operative use beyond 14 days.

    Opioid Tapering

    Taper coverage is allowed when the patient is above 50 MED/day or has concurrent benzodiazepine and/or antipsychotic therapy.

    Taper coverage: The patient is receiving more than 50 MED/day or concurrent benzodiazepine and/or antipsychotic therapy; a taper is clinically appropriate; and the provider documents the taper plan and reduction in daily MED when the taper extends beyond 90 days.90-day standard taper period; no maximum taper timeframe

    A taper period may be covered to reach 50 MED/day or less or to address unsafe concurrent therapy.

    The policy requirements do not apply to individuals receiving hospice care, palliative care, or cancer treatment, residents of qualifying long-term care facilities under 42 USC 1396a(oo)(3)(A)(ii), or individuals with sickle cell disease. Individuals in these categories should continue to have appropriate access to opioid treatment.

    Long-term opioid coverage is excluded for conditions for which sustained opioid treatment is considered ineffective or insufficiently supported, including low back pain, headache, including migraine headache, and fibromyalgia. Fibromyalgia is also identified as a non-funded condition under the October 1, 2021 Prioritized List of Health Services.

    Coverage is excluded for current alcohol or illegal substance use, concurrent use of two short-acting opioids, or concurrent use of a long-acting and short-acting opioid. Concurrent opioid therapy with a benzodiazepine or antipsychotic is also excluded because of increased adverse-event risk, except when coverage is requested during an approved taper with a documented taper plan.

    Long-term opioid treatment is not supported as a covered benefit for painful conditions that the CDC or another regulatory entity has determined to be ineffective or to have insufficient evidence for improving pain or function with long-term opioid use.

    Coverage and Utilization Thresholds

    New chronic opioid therapy maximum dose
    Maximum dose50 mg MED per day
    Applies toNew starts on chronic opioid therapy
    Coverage conditionAll applicable coverage criteria must be met
    Post-operative opioid coverage
    Coverage periodUp to 14 days following surgery
    Extended useJustification is required for ongoing use beyond 14 days
    Medication typePost-operative pain medication

    Prior Authorization and Documentation

    Prior Authorization

    Extended-Release Opioid Prior Authorization

    Obtain prior authorization for all extended-release opioid prescriptions. For pain related to the back or spine, the request must also meet the requirements of Guideline Note 60, Opioids for Conditions of the Back and Spine, in the Oregon Health Plan Prioritized List.

    Prior Authorization

    High-Dose Opioid Exception

    Doses greater than 50 MED per day may be covered through prior authorization when the required risk assessment, monitoring, and functional treatment documentation support the exception.

    • Annual SBIRT questionnaire, AUDIT, and DAST completed
    • Urine drug screen submitted
    • Oregon Prescription Drug Monitoring tool reviewed for inconsistencies or aberrancies
    • Functional treatment goals established and submitted with the request

    Policy Background

    This policy addresses opioid-related adverse drug events, diversion, misuse, and overdose risk in chronic and acute pain treatment. It applies dose, duration, refill, drug-combination, monitoring, and tapering controls consistent with federal and Oregon opioid-safety requirements and evidence regarding the effectiveness of long-term opioid therapy.

    Definitions

    Chronic use
    DefinitionChronic use is dispensing 60 tablets
    Lookback period180-day period
    Included medicationsAny combination of opioid or opioid-type medication
    Maximum daily morphine equivalent dose
    DefinitionThe total of all opioids prescribed to the patient
    Included opioid typesShort-acting and long-acting opioids
    MeasurementDaily morphine equivalent dose

    Initial Therapy Criteria

    Initial Opioid Therapy

    Initial opioid therapy is covered only when the indication, safety, dose, and duration requirements are met.

    Initial opioid therapy: The indication is funded and clinically supported; required diagnosis documentation is submitted; the patient has no excluded substance use or unsafe concurrent opioid/drug combination; a new chronic start is at or below 50 MED/day; a new short-acting start complies with the 7-day supply, 90 MED/day hard threshold, 50 MED/day soft threshold, and 85% refill rules; and an extended-release opioid has prior authorization.50 MED/day for new chronic therapy; 7-day supply and 90 MED/day hard threshold for new short-acting therapy

    Exceptions may be requested through prior authorization when the policy's monitoring and risk-screening requirements are met.

    Continuation Criteria

    Chronic Opioid Continuation

    Continuation therapy is subject to ongoing safety, dose, monitoring, and taper requirements.

    Continuation of chronic opioid therapy: The underlying condition remains funded and clinically supported; required monitoring and documentation remain current; total opioid exposure is assessed using all prescribed opioids; prohibited concurrent therapies and substance use are absent or are being tapered; and the patient is maintained at 50 MED/day or less unless a documented high-dose exception is approved.50 MED/day target

    No maximum timeframe is enforced for an opioid taper.

    Quantity Limits

    Post-operative opioid medication
    Coverage limitUp to 14 days following surgery
    Extended treatmentJustification is required for ongoing use beyond 14 days
    Related limitNew starts of short-acting opioids are limited to a 7-day supply
    New short-acting opioids
    Supply limit7-day supply
    Applies toNew starts of short-acting opioids
    Dose safety editA 90 MED/day point-of-sale hard threshold applies
    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 ReviewDec 1, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization for all extended-release opioid prescriptions.
    SourceLink
    On This Page
    Coverage CriteriaCoverage and Utilization ThresholdsPrior Authorization and DocumentationPolicy BackgroundDefinitionsInitial Therapy CriteriaContinuation CriteriaQuantity Limits
    New short-acting opioid supply
    Supply limit7-day supply
    Applies toNew starts of short-acting opioids
    Related safety controlA 90 MED/day point-of-sale hard threshold also applies
    New short-acting opioid hard threshold
    Hard threshold90 MED/day
    Applies atPoint of sale
    ExceptionsMay be requested through prior authorization after required risk screening and Oregon Prescription Drug Monitoring Program review
    New short-acting opioid soft threshold
    Soft threshold50 MED/day
    OverrideOverridable by pharmacy submitting an appropriate DUR code
    Applies toNew starts of short-acting opioids
    Refill threshold
    Refill threshold85%
    Applies toOpioid prescriptions
    BasisConsistent with the general refill threshold for other controlled and non-controlled substances
    Chronic opioid use
    Chronic use threshold60 tablets
    Time periodWithin a 180-day period
    Medication covered by definitionAny combination of opioid or opioid-type medication dispensed by the pharmacy
    Prior Authorization

    Acute Opioid Safety-Edit Exception

    Request prior authorization for an exception to the 90 MED/day hard threshold applied at point of sale to new starts of short-acting opioids. The exception request must include the required risk screening and documentation that the Oregon Prescription Drug Monitoring Program was reviewed.

    • The 90 MED/day limit is a hard point-of-sale threshold for new short-acting opioid starts
    • A 50 MED/day soft threshold may be overridden by the pharmacy using the appropriate DUR code
    Prior Authorization

    Taper Authorization

    A 90-day taper period is allowed for patients receiving more than 50 MED/day or concurrent benzodiazepines and/or antipsychotics. Submit a prior authorization request when coverage of the taper is needed.

    • The taper is intended to reach 50 MED/day or less when the patient is above that dose
    • No maximum timeframe is enforced for opioid tapers
    Documentation Required

    Diagnosis and Examination Support

    For chronic opioid coverage, submit chart notes and a physical examination supporting a diagnosis funded for coverage by the Oregon Health Plan. Coverage determinations require documentation supporting the funded diagnosis.

    • Include the relevant diagnosis in the submitted clinical record
    • Document examination findings that support the diagnosis

    Unsupported block type: documentation

    Documentation Required

    High-Dose Risk Documentation

    For a prior authorization request involving a dose greater than 50 MED/day, submit the complete high-dose risk documentation used to support the exception.

    • Annual SBIRT questionnaire
    • AUDIT and DAST screening
    • Urine drug screen
    • Oregon Prescription Drug Monitoring tool review for inconsistencies or aberrancies
    • Established functional treatment goals
    Documentation Required

    Extended Taper Documentation

    If more than 90 days are required to taper safely to 50 MED/day or less, submit a tapering plan with the prior authorization request. The chart and dispensing history must support a documented reduction in the daily MED prescribed.

    • Include the proposed taper schedule and clinical rationale
    • Document dose reductions in the chart
    • Provide dispensing-history support for the reduction
    Documentation Required

    Acute Threshold Exception Documentation

    To request an exception to the 90 MED/day hard threshold for a new short-acting opioid start, complete the required risk screening and review the Oregon Prescription Drug Monitoring Program before submitting the request.

    • Document the applicable patient risk screening
    • Document review of the Oregon Prescription Drug Monitoring Program
    • Submit the findings with the prior authorization request
    Documentation Required

    Benzodiazepine Taper Plan

    Concurrent benzodiazepine and opioid therapy is not covered because of increased adverse-event risk. A taper period may be covered when a documented taper plan is submitted with the prior authorization request.

    • Include the taper plan in the prior authorization submission
    • The opioid-benzodiazepine point-of-sale safety edit is bi-directional and may deny either drug when overlapping prescription fill history exists
    Denial Risk

    Unfunded or Unsupported Indication

    Chronic opioids are not covered for painful conditions that the CDC or another regulatory entity has determined to be ineffective or insufficiently supported for improved pain or function with long-term opioid use. Fibromyalgia is identified as a non-funded condition on the October 1, 2021 Prioritized List.

    • Examples include low back pain and headache, including migraine headache
    • Confirm that the indication is funded and supported before requesting chronic opioid coverage
    Denial Risk

    Unsafe Concurrent Therapy or Substance Use

    Chronic opioids are not covered for patients currently using alcohol or other illegal substances. Concurrent opioid therapy with benzodiazepines or antipsychotics is also not covered because of increased risk of adverse events, except that a documented taper period may be authorized.

    • Two short-acting opioids may not be covered concurrently
    • Long-acting and short-acting opioid combinations are not covered because of safety concerns and potential dose escalation
    • The opioid-antipsychotic point-of-sale edit is one-directional and denies the opioid claim
    Denial Risk

    Acute Opioid Safety Edits

    New short-acting opioid claims may be denied when acute opioid safety edits are exceeded. Apply the applicable supply, refill, and dose limits or obtain an approved exception before dispensing.

    • 7-day supply limit for new short-acting opioid starts
    • 90 MED/day hard point-of-sale threshold
    • 50 MED/day soft threshold, overridable by the pharmacy with the appropriate DUR code
    • 85% refill threshold
    Denial Risk

    Unauthorized Extended-Release Opioid

    Claims for extended-release opioids may be denied when the required prior authorization has not been obtained. For back- or spine-related pain, the authorization must also satisfy Guideline Note 60 requirements.

    • Prior authorization is required for all extended-release opioid prescriptions
    • Submit the authorization before dispensing
    SUPPORT ACT
    Full nameSubstance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act
    PurposeDesigned to reduce opioid-related fraud, misuse, and abuse
    Section 1004 requirementRequires states to implement minimum opioid standards