CurrentAnthemPolicy N/A

Long Acting & Short Acting Opioids Daily Dose Limits -Cardinal Care Medicaid PDF

This document is a prior authorization (PA) request form and criteria summary for short-acting and long-acting opioid prescriptions for Anthem HealthKeepers Plus (Virginia Medicaid), describing when PA is required, authorization lengths by diagnosis, required attestations, alternative therapies, and documentation fields required for approval.

Policy Summary

PayerAnthem

PolicyLong Acting & Short Acting Opioids Daily Dose Limits -Cardinal Care Medicaid PDF

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete and sign the PA form and include all requested information; incomplete forms will delay PA and should be faxed to 844-512-7020.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

3Authorization Durations (months)

90PA MME Threshold

7Short-Acting Acute Limit (days)

Coverage Summary

This is a prior authorization (PA) policy and request form for short-acting and long-acting opioid prescriptions for Anthem HealthKeepers Plus (Virginia Medicaid). The policy stance is covered with criteria: long-acting opioids require PA, and short-acting opioids may require PA when limits are exceeded. The form describes when PA is required, documentation and attestation fields, and authorization lengths by diagnosis for members covered under Anthem HealthKeepers Plus.

Prior Authorization Criteria

When Service Authorization (PA) is Required

Prior authorization (PA) is required when ANY of the following conditions are met. Complete the applicable attestations and documentation to avoid delays.

All long-acting opioids.

Any short-acting opioid prescribed for > 7 days or two 7-day supplies in a 60-day period.

Any cumulative opioid prescription exceeding 90 morphine milligram equivalents (MME) per day. Quantity limits apply to each drug.

Length of Authorization by Diagnosis

Length of authorization is determined by diagnosis. Select any that apply to support the requested duration.

Length of authorization: 3 months for any of the following diagnoses: HIV/AIDS; Chronic back pain; Arthritis; Fibromyalgia; Diabetic neuropathy; Postherpetic neuralgia; Other (specify).

Length of authorization: 6 months for any of the following diagnoses: Cancer pain; Sickle cell disease; Palliative care; End-of-life care; Hospice patient.

Exemptions / Simplified Approval

Exemptions / simplified approval: PA may be approved with a signed attestation and minimal additional documentation when ANY of the listed exemptions apply. Indicate which exemption and provide the required attestation.

Member has pain associated with cancer, palliative care (treatment of symptoms associated with life-limiting illnesses), sickle cell disease, or hospice care (IF YES, SIGN AND SUBMIT — NO FURTHER INFORMATION REQUIRED unless a non-preferred is prescribed).

Member is in remission from cancer and the prescriber is safely weaning the member off opioids with a tapering plan (IF YES, SIGN AND SUBMIT — NO FURTHER INFORMATION REQUIRED unless a non-preferred drug is prescribed).

Member resides in a long-term care facility (IF YES, SIGN AND SUBMIT — NO FURTHER INFORMATION REQUIRED unless a non-preferred/non-formulary drug is prescribed).

Non-preferred Product Requirement

Non-preferred Schedule II products require documentation of prior trials. ALL conditions below must be met for non-preferred Schedule II opioid approval.

Has the member tried and failed an adequate trial of 2 different preferred products? (If yes, list drug name, length of trial, and reason for discontinuation).

MME and High-Dose Attestation

MME threshold and attestation. Enter the member's Active Daily MME from the PMP.

MME: (numeric entry required)

If member's Active Daily MME is greater than or equal to 90, prescriber must attest that they will be managing the member's opioid therapy long term, have reviewed the Virginia BOM Regulations for Opioid Prescribing, have prescribed naloxone, and acknowledge the warnings associated with high-dose opioid therapy including fatal overdose, and that therapy is medically necessary for this member.

Concomitant Benzodiazepine Use

Concomitant benzodiazepine use requires prescriber attestation when a benzodiazepine has been filled in the past 30 days. ALL statements below must be affirmed when applicable.

If a benzodiazepine prescription has been filled in the past 30 days, prescriber attests they have counseled the member on the FDA black box warning regarding combined opioid and benzodiazepine use, have documented that the combination therapy is medically necessary, and have recorded a tapering plan to achieve the lowest effective doses of both opioids and benzodiazepines per the Board of Medicine Opioid Prescribing Regulations.

Naloxone Consideration

Naloxone consideration: prescribers should evaluate overdose risk and document naloxone prescribing when risk factors are present. ANY of the listed risk factors support naloxone prescribing.

Has naloxone been prescribed for members with overdose risk factors? Risk factors include substance use disorder, doses in excess of 50 MME/day, concomitant antihistamines, antipsychotics, benzodiazepines, gabapentin, pregabalin, tricyclic antidepressants, or the 'Z' drugs (zopiclone, zolpidem, zaleplon). Prescriber attests Yes/No.

Prescriber attests that naloxone was prescribed or offered when risk factors are present and documentation is included.

Reproductive-Age Counseling

Reproductive-age counseling: for members of childbearing potential aged 18–45, prescriber must attest that counseling occurred. ALL of the following must be addressed when applicable.

If member is of childbearing potential and between 18 and 45 years old, prescriber attests they discussed the risk of neonatal abstinence syndrome and provided counseling on contraceptive options.

Prior Trials of Non-Opioid Therapies

Prior trials of non-opioid therapies. Select ANY of the therapies the member has tried and failed to support need for opioid therapy.

Baclofen

Capsaicin gel

Duloxetine

Gabapentin

Lidocaine 5% patch

NSAIDs (oral)

Physical therapy

Codes and Formularies

Preferred Long-Acting Opioids (examples)mixedCovered

butrans_patch	Butrans® (buprenorphine) transdermal patch — preferred long-acting option (schedule III-V for buprenorphine formulations).
fentanyl_patches	Fentanyl transdermal patches — 12, 25, 50, 75, and 100 mcg/hr strengths (preferred long-acting opioid examples; Schedule II).

Preferred Short-Acting Opioids (examples)mixedCovered

codeine_apap	Codeine with acetaminophen (short-acting) — preferred short-acting opioid example.
hydrocodone_apap	Hydrocodone with acetaminophen — preferred short-acting opioid example.
hydrocodone_ibuprofen	Hydrocodone with ibuprofen — preferred short-acting opioid example.
hydromorphone_ir	Hydromorphone immediate release — preferred short-acting opioid example.
morphine_ir	Morphine immediate release — preferred short-acting opioid example.
oxycodone_ir	Oxycodone immediate release — preferred short-acting opioid example.
oxycodone_apap	Oxycodone with acetaminophen — preferred short-acting opioid example.
tramadol_hcl_50mg	Tramadol HCl 50 mg — preferred short-acting opioid example.
tramadol_apap	Tramadol with acetaminophen — preferred short-acting opioid example.

Non-preferred / Examples Requiring Trial (e.g., Schedule II long-acting formulations)mixed

avinza	Avinza® (morphine ER) — example non-preferred long-acting opioid; requires trial/failure of preferred products prior to approval.
kadian	Kadian® (morphine ER) — example non-preferred long-acting opioid; requires prior trial of preferred alternatives.
embeda	Embeda® (morphine/naltrexone) — example non-preferred product requiring prior trials of preferred agents and documentation of failure/intolerance.

Provider Actions & Documentation Requirements

Prior Authorization

Submit completed PA form for opioids meeting PA criteria

Providers must complete and sign the PA form and include all requested information. Fax the completed form to 844-512-7020. Incomplete, incorrect, or illegible forms will delay the PA process.

Documentation Required

Document trials of preferred therapies

For requests for non-preferred Schedule II opioids, document trials of two different preferred products. For each trial include the drug name, length of trial, and reason for discontinuation.

Documentation Required

Report Active Daily MME from PMP

Provide the member's Active Daily MME from the Virginia PMP (https://virginia.pmpaware.net/login) on the PA form. If the Active Daily MME is greater than or equal to 90, attest that you will manage the member's opioid therapy long term, have reviewed the Virginia Board of Medicine regulations, have prescribed naloxone, acknowledge high-dose opioid warnings (including fatal overdose), and that therapy is medically necessary.

Documentation Required

Attestations for benzodiazepine co-prescribing

If a benzodiazepine prescription was filled in the past 30 days, attest that you counseled the member on the FDA black box warning about combined opioid and benzodiazepine risks (including fatal overdose), documented that therapy is medically necessary, and recorded a tapering plan to achieve the lowest effective doses per Virginia Board of Medicine regulations.

Documentation Required

Naloxone prescribing for overdose risk

Indicate on the PA form whether naloxone has been prescribed for members with overdose risk factors (e.g., substance use disorder; doses >50 MME/day; concomitant antihistamines, antipsychotics, benzodiazepines, gabapentin, pregabalin, tricyclic antidepressants, or Z-drugs).

Documentation Required

Counseling for reproductive-age patients

If the member is female of childbearing potential aged 18–45, document that you discussed the risk of neonatal abstinence syndrome and provided counseling on contraceptive options.

OpenPayer

Long Acting & Short Acting Opioids Daily Dose Limits -Cardinal Care Medicaid PDF

Coverage Summary

Prior Authorization Criteria

Codes and Formularies

Provider Actions & Documentation Requirements

Background