CurrentAnthemPolicy VABCBS-CD-029382-23-SRS28031

Short Acting & Long Acting Opioids Daily Dose Limits — Anthem HealthKeepers Plus (VA)

Defines daily quantity/dose limits for short-acting (SAO) and long-acting opioids (LAO) for Anthem HealthKeepers Plus Medicaid in Virginia and describes prior authorization requirements for supplies exceeding limits.

Policy Summary

PayerAnthem

PolicyShort Acting & Long Acting Opioids Daily Dose Limits — Anthem HealthKeepers Plus (VA)

Policy CodePolicy VABCBS-CD-029382-23-SRS28031

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a Prior Authorization form (fax 844-512-7020) for any doses or quantities above the listed daily limits or for supplies exceeding seven days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7-daymaximum VA supply without prior authorization

PA requiredauthorization requirement

HealthKeepers Plus (VA)plan scope

Largeproduct list

Coverage Criteria

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Standard coverage criteria

Covered when ALL of the following are met

Within specified daily limits: Prescribed opioid agent and dosage do not exceed the per-product daily dose limit listed in the policy table.per-product daily limits listed

See product tables in document

Supply duration: Supply is for seven (7) days or less for Virginia Medicaid members.<= 7 days

Supplies exceeding 7 days require prior authorization

Listed Opioid Products & Coding Limits

Listed opioid products and associated daily dose limits (SAO and LAO)NDC|mixed

APAP /CODEINE	Daily Dose limit = .
APAP-Codeine 120-12mg; 300-12mg sol	Daily Dose limit = 150 ml 10.
APAP-Codeine 120-12mg; 300-12mg sol (alternate)	Daily Dose limit = 180 ml.
APAP-Codeine 300mg/15, 30 , 60 mg	Daily Dose limit = 10.
CODEINE	Daily Dose limit = .
Codeine Sulfate 15 mg	Daily Dose limit = 24.
Codeine Sulfate 15 mg (alternate)	Daily Dose limit = 120 ml.
Codeine Sulfate 30 mg	Daily Dose limit = 12.
Codeine Sulfate 60 mg	Daily Dose limit = 6.
Oxycodone HCL 5 mg	(listed among products)

1–10 of 61

1/7

Maximum no-PA supply — Virginia

Maximum no-PA supply (VA)Seven (7) day supply — supplies exceeding 7 days require Prior Authorization.

Prior Authorization submissionPrior Authorization form must be completed and faxed to 844-512-7020 for supplies >7 days.

Form availabilityPA fax forms available at Anthem provider site: https://providers.anthem.com/virginia-provider/resources/forms

Plan scopeApplies to Anthem HealthKeepers Plus Medicaid (Virginia).

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization required — Prior authorization is required for any doses/quantities above the listed daily limits or for supplies exceeding a seven (7) day supply for Virginia members. To request prior authorization, complete the Virginia Prior Authorization form and fax to 844-512-7020. Fax forms are available at: https://providers.anthem.com/virginia-provider/resources/forms

Applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.
Required when doses/quantities exceed listed daily limits for short-acting or long-acting opioids.
Required when supply exceeds a seven (7) day supply (Virginia).

Note

Provider action: follow the instructions on the prior authorization form and submit all required documentation. If unsure which form to use or for assistance, contact the provider help line or refer to the Virginia provider resources at the link above.

Complete and fax the Prior Authorization form to 844-512-7020.
Include clinical rationale and supporting documentation with the PA submission.

Prior Authorization

Prior Authorization and Submission

Prior Authorization and submission — If doses or quantities exceed the listed daily dose limits for short-acting or long-acting opioids, or if the requested supply exceeds a seven (7) day supply for Virginia, a completed Prior Authorization form must be submitted and received prior to coverage consideration. Incomplete submissions may delay processing.

Doses above daily limits for LAO or SAO require PA.
Requests for supplies >7 days (Virginia) require PA.

Denial Risk

7-day Supply Limit — Denial Risk

7-day supply limit — Requests for quantities exceeding a seven (7) day supply for Virginia members without a prior authorization will be denied.

Virginia allows a maximum seven (7) day supply; quantities beyond this will be denied without PA.
Denial risk applies to both short-acting and long-acting opioid prescriptions when limits are exceeded and no PA is on file.