Opioid Analgesic Quantity Limits (Pharmacy Point-of-Sale)
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Establishes maximum daily pharmacy point-of-sale quantity limits for opioid analgesics for Alaska Medicaid claims, with override and prior authorization processes for specific patient groups. Applies to prescribers, pharmacists, and pharmacy claims processing for Alaska Medicaid recipients.
No material clinical or coverage changes in this revision.
Opioid Analgesic Quantity Limits and Exceptions
Opioid quantity limit rule
Covered when the conditions below are met:
A listing of the opioid analgesic daily quantity limits is available online.
Exception pathways
- Site-of-care override: Cancer pain: Override permitted when the patient is being treated for cancer pain and the prescriber or pharmacist enters '11' in the Patient Location field on the pharmacy claim.
- Site-of-care override: Hospice: Override permitted when the patient is in hospice and the prescriber or pharmacist enters '2' in the PA Type field on the pharmacy claim.
- Site-of-care override: Long term care: Override permitted when the patient is in long term care and the prescriber or pharmacist enters '4' in the Patient Location field on the pharmacy claim.
- Prior authorization for CNCP exceedance: Requests to exceed the maximum daily quantity limits for chronic non-cancer pain (CNCP) require prior authorization; prescriber requests will be reviewed on a case-by-case basis.
Recipients being treated for cancer pain, those in hospice, and those in long term care are eligible for a claim-based override of the programmed opioid quantity limits. To request an override at the time of dispensing, the prescriber or pharmacist must enter the specified code in the pharmacy claim: for cancer pain enter 11 in the Patient Location field; for hospice enter 2 in the PA Type field; for long term care enter 4 in the Patient Location field. Use of these codes for recipients not meeting the corresponding condition may result in an overpayment that will be recouped by the Department.
Claim Processing Codes and Quantity Values
| 11 | Enter '11' in Patient Location field to indicate Cancer Pain |
| 2 | Enter '2' in PA type field to indicate Hospice |
| 4 | Enter '4' in Patient Location field to indicate Long Term Care |
Prescriber and Pharmacist Actions, Overrides, and Prior Authorization
Prior authorization required to exceed daily limits for CNCP
Claims for recipients being treated for chronic non-cancer pain (CNCP) that exceed the maximum daily limits require prior authorization and clinical review. Requests from the prescriber to exceed the daily quantity limits for CNCP will be reviewed on a case-by-case basis.
Other important provider obligations
Provider action: watch for other high-priority obligations or alerts from Alaska Medicaid related to opioid dispensing limits, PA processes, or claim submissions.
Claim field overrides for cancer, hospice, and long term care
To override programmed quantity limits at point of sale for patients being treated for cancer pain, in hospice, or in long term care, the prescriber or pharmacist must enter the specified codes on the pharmacy claim in the indicated fields. Overrides applied using these codes for patients who do not meet the indicated condition may result in overpayment and recoupment by the Department.
- Cancer pain: Enter '11' in Patient Location field
- Hospice: Enter '2' in PA Type field
- Long Term Care: Enter '4' in Patient Location field
Point-of-sale denials when daily limits are exceeded
Claims submitted at point of sale that exceed the programmed maximum daily quantity limits will deny. For CNCP cases, submit a prior authorization request for exceedance; for cancer, hospice, or long term care cases, use the appropriate claim override code to prevent denial.
Policy Rationale and Program Context
The Drug Utilization Review Committee implemented prospective DUR quantity limit edits for opioid analgesics to reduce excessive supply and address the national epidemic of unintentional overdose fatalities related to prescription medications. Under this policy, claims for opioid analgesics have a programmed maximum daily quantity; any claim exceeding that limit will deny at point-of-sale. Requests to exceed the maximum daily limits for recipients being treated for chronic non-cancer pain (CNCP) require prior authorization and will be reviewed on a case-by-case basis. A detailed listing of the per-drug daily quantity limits is available on the Alaska Medication Prior Authorization website.
Key Terms
Opioid Analgesic Product Limits
Overrides by Care Setting
Overrides allowed for cancer, hospice, and long term care with claim codes
Quantity limit overrides are permitted when the recipient is being treated for cancer pain, is in hospice, or is in long term care, but the appropriate claim field code must be submitted to effect the override.
- Cancer Pain: enter '11' in Patient Location.
- Hospice: enter '2' in PA Type.
- Long Term Care: enter '4' in Patient Location.
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