Alternatives to Opioid Medications
Customize your policy alerts
Sign up for all allcarehealthcco policy alerts
Know when allcarehealthcco releases new policies or updates existing guidance.
Monitor payer policy activity
Lists non-opioid treatment options available to AllCare Health CCO members and providers, with referral and prior authorization guidance where applicable. Affects AllCare CCO members and their providers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Available Alternatives
Covered alternatives and authorization requirements
Coverage stance for listed alternatives
Counseling specifically noted as available without referral for mental health or substance use; AllCare Wellness available when requested by PCP; services must be provided by an AllCare contracted/recognized provider.
Services must be provided by an AllCare Health contracted and/or recognized provider.
Document does not list specific drugs or step therapy criteria.
This document provides a non‑exhaustive list of suggested alternatives to opioid medications for AllCare Health CCO members. It explicitly states the list is not all‑inclusive and directs providers to contact AllCare with questions about services not listed. The intent is to present available options and guidance rather than to establish exhaustive coverage exclusions or mandatory treatment sequences.
Coding
| No codes listed |
Provider Actions, Referrals, and Authorization
Acupuncture — obtain prior authorization
Acupuncture requires prior authorization and must be referred by the member’s Primary Care Provider (PCP) with a prescription; obtain PA before scheduling to avoid denial or nonpayment.
- Available with prior authorization approval when referred by Primary Care Provider (PCP) with a prescription.
Chiropractic — obtain prior authorization
Chiropractic manipulation requires prior authorization and must be referred by the PCP with a prescription; secure PA prior to services to prevent claim denials.
- Available with prior authorization approval when referred by PCP with a prescription.
PT/OT — obtain prior authorization
Physical or occupational therapy is available only with prior authorization when requested by the PCP with a prescription; request PA at time of referral to ensure coverage.
- Available with prior authorization approval when requested by PCP with a prescription.
TENS units — obtain prior authorization
TENS units require prior authorization when requested by the PCP with a prescription; confirm PA approval before dispensing or billing the device.
- Available with prior authorization approval when requested by PCP with a prescription.
Use AllCare formulary alternatives and follow pharmacy rules
Prescribe alternative medications from the AllCare CCO formulary and follow pharmacy formulary and step-edit rules for access; verify member’s formulary coverage and any applicable pharmacy edits.
- Many alternative medications available on the AllCare CCO formulary to the member with a prescription.
- Formulary access and any step edits follow the pharmacy formulary rules (per policy note).
PCP referral, prescription, and contracted provider required
All services requiring prior authorization must be referred/requested by the PCP with a prescription and must be provided by an AllCare Health contracted and/or recognized provider; lack of required PA or noncontracted provider status may result in denial or nonpayment.
- Services listed as available with prior authorization approval must be referred/requested by PCP with a prescription.
- All services must be provided by an AllCare Health contracted and/or recognized provider.
Prior authorization required for select services — risk of denial
Services listed as “Available with prior authorization approval” (acupuncture, chiropractic manipulation, PT/OT, TENS units) require prior authorization when referred/requested by the PCP with a prescription; submitting services without PA may trigger denial or nonpayment.
- Acupuncture, chiropractic manipulation, physical/occupational therapy, and TENS units are available with prior authorization approval when referred/requested by PCP with a prescription.
Background
Purpose: to summarize non‑opioid treatment options and supportive programs available to AllCare Health CCO members and their providers. Scope: the document lists suggested alternatives (for example, counseling and self‑management programs) and notes that these are suggestions, not an exhaustive catalog of covered services. Providers should contact AllCare for clarification or to inquire about services not included in this list.
Definitions and Suggested Alternatives
Conservative Treatment Requirements
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.