CurrentAnthemPolicy N/A

Prior authorization requirements for short- and long-acting opioid prescriptions

This PA form governs prior authorization requirements for short-acting and long-acting opioid prescriptions for Anthem HealthKeepers Plus Medicaid members in Virginia (Anthem/HealthKeepers, Inc.). It informs prescribers what must be documented and attested for coverage decisions.

Policy Summary

PayerAnthem

PolicyPrior authorization requirements for short- and long-acting opioid prescriptions

Policy CodePolicy N/A

Change TypeNo material change

Effective Date07/01/2023

Next Review DateN/A

Key ActionSubmit a completed PA form with required demographics, prescriber NPI and signature, documentation of prior trials and MME, and attestations to support approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysmax acute short-acting w/o PA

90MME threshold

3/6 moauth length

AllLAOs require PA

Coverage criteria and guidance

Coverage criteria and required attestations

Authorization length and required attestations. Covered when ALL of the following apply:

General PA triggers: PA is required for all long-acting opioids; for short-acting opioids prescribed >7 days or two 7-day supplies in a 60-day period; and for any cumulative opioid prescription exceeding 90 MME/day.

Based on PA form and Virginia Board of Medicine regulations

Authorization length determination: Authorize for 3 months when diagnosis is one of: HIV/AIDS, chronic back pain, arthritis, fibromyalgia, diabetic neuropathy, postherpetic neuralgia, or other specified; authorize for 6 months when diagnosis is cancer pain, sickle cell disease, palliative care, end-of-life care, or hospice.

Prescriber must check applicable diagnosis box on form

Exemptions requiring only signature: If member has intractable pain from active cancer, is in palliative or hospice care, or is in a long-term care facility (or is in cancer remission with a tapering plan), prescriber may sign and submit with no further information required unless a non-preferred drug is prescribed.

Policy Summary

PayerAnthem

PolicyPrior authorization requirements for short- and long-acting opioid prescriptions

Policy CodePolicy N/A

Change TypeNo material change

Effective Date07/01/2023

Next Review DateN/A

Key ActionSubmit a completed PA form with required demographics, prescriber NPI and signature, documentation of prior trials and MME, and attestations to support approval.

SourceLink

On This Page

Key dosing thresholds and limits

Active Daily MME threshold

Active daily MME threshold>= 90 morphine milligram equivalents (MME) per day

Action when threshold metPrescriber must attest to long-term management of opioid therapy, review of Virginia BOM regulations, prescribe naloxone, and acknowledge high-dose warnings

Source for MME valueForm requires active daily MME from the PMP (question 6) to determine if threshold is met

Short-acting opioid acute prescribing limit (per VA BOM)

Acute short-acting opioid prescribing limit7 days (Virginia Board of Medicine limit for treatment of acute pain)

When PA is required for short-acting opioidsAny short-acting opioid prescribed for >7 days or two 7-day supplies in a 60-day period requires prior authorization

Source noteLimit referenced in drug information section of the PA form

What the prescriber must do when requesting authorization

Prior Authorization

Prior Authorization Required

Prior Authorization is required for all long-acting opioids and for short-acting opioids 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 also requires prior authorization. Use one form per member. Incomplete, incorrect, or illegible submissions can delay or result in denial of the PA.

All long-acting opioids require PA.
Short-acting opioids require PA when prescribed >7 days or two 7-day supplies in 60 days.
Prescriptions with cumulative daily dose >= 90 MME require PA.
Use one PA form per member; incomplete forms may delay or deny processing.

Documentation Required

Required Form Elements

The PA form must include complete member and prescriber demographics, drug details, and required attestations. Ensure legible entries for all requested fields to avoid delays.

Member information: Last name, First name, Medicaid ID number, DOB, Gender, Weight (kg).
Prescriber information: Last name, First name, NPI number, Phone, Fax.
Drug information: Indicate Short-Acting, Long-Acting, or Both; list drug name/form, strength, dosing frequency, length of therapy, and quantity per day for each drug.
Prescriber signature and date (required).

Documentation Required

Clinical Documentation and Attestations

Provide clinical documentation and attestations to support medical necessity, prior trials, and safety monitoring. Include diagnosis, duration requested, prior trial details, current MME, and risk mitigation steps.

Diagnosis and requested length of authorization: indicate applicable diagnosis boxes (3 months vs 6 months options).
Attest if member has intractable pain related to active cancer, palliative or hospice care, or is in remission with a taper plan — if yes, sign and submit (no further info required unless non-preferred drug).
Document trials and failures of preferred non-opioid therapies (select from Baclofen, Capsaicin gel, Duloxetine, Gabapentin, or list other preferred therapies tried).
If requesting a non-preferred product, document adequate trials and failures of 2 different preferred products (name, length of trial, reason for discontinuation).
Report Active Daily MME from the PMP and, if >= 90 MME/day, attest to long-term management plan, review of regulations, naloxone prescription, and acknowledgement of high-dose risks.
If benzodiazepine filled in past 30 days, attest counseling on combined use risks, documentation of medical necessity, and existence of a taper plan.
Indicate whether naloxone has been prescribed when overdose risk factors are present.

Step Therapy

Prior Trials / Alternative Therapy Requirements

Prescribers must document failure of appropriate alternative therapies prior to approval for opioid therapy. Non-opioid and non-pharmacologic options should be considered first.

Document trial and failure of non-opioid/alternative therapies available without PA (e.g., NSAIDs topical/oral, SNRIs, TCAs, Gabapentin, Baclofen, Capsaicin 0.025%, Lidocaine 5% patch, Pregabalin).
For non-preferred Schedule II opioid requests, indicate two adequate trials of different preferred products and reasons for discontinuation.
Reference Virginia Board of Medicine Opioid Prescribing Regulations and the VA Medicaid PDL for covered alternatives.

Denial Risk

Incomplete Submission Risk

Prescriber signature is required. Omitting signature, dates, NPI, or key clinical fields (diagnosis, MME, prior trials) will delay processing and may result in denial.

Required: Prescriber signature and date confirming accuracy and verifiability by member records.
Ensure NPI is provided and contact/fax numbers are legible.
Incomplete or illegible forms may be returned or denied; submission does not guarantee coverage.

Prior Authorization

High-Dose or Long-Duration Opioid Prescriptions

High-dose (>=90 MME/day) or long-duration opioid prescriptions require additional attestations and risk mitigation steps.

If Active Daily MME >= 90, prescriber must attest to long-term management of opioid therapy, review of Virginia BOM regulations, prescription of naloxone when appropriate, and acknowledgement of overdose risk.
Short-acting opioids prescribed for >7 days require PA and documentation of prior trials/justification per Virginia BOM regulations.
When benzodiazepine co-prescription exists, document counseling, medical necessity, and a tapering plan.

Required prior therapies and step therapy

Conservative treatment and prior-therapy attestations

Conservative treatment requirements — prescriber must select prior therapies tried on the PA form. Approval requires documentation of prior trials as specified below:

Document prior conservative therapies: Prescriber must indicate on the PA form which covered non-opioid and non-pharmacologic therapies the member has tried and failed (select all that apply). Examples listed on the form include: baclofen; capsaicin gel/cream; duloxetine; gabapentin; lidocaine 5% patch; oral NSAIDs; physical therapy; tricyclic antidepressants (e.g., nortriptyline); cognitive behavioral therapy; and other listed alternatives.

See question 4 and following therapy checklist on form

Non-preferred opioid requirement: When requesting a non-preferred opioid product (e.g., Avinza®, Kadian®, Embeda®), the prescriber must confirm the member tried and failed an adequate trial of two different preferred products and must list each drug name, length of trial, and reason for discontinuation.

See question 5 on form

Form completion requirement: Selections of prior therapies and documentation of trials must be entered on the PA form; incomplete selection or missing details may delay processing or result in denial.

Provider must complete applicable checklist items on form

Clinical background and scope

Long-acting opioids are reserved for patients with chronic, moderate to severe pain requiring around-the-clock opioid treatment. Before authorizing long-acting agents, prescribers should document trials of conservative and non-pharmacologic measures (for example, NSAIDs, topical agents, SNRIs, TCAs, gabapentin, physical therapy, or CBT) and follow the VA Board of Medicine guidance referenced on the form. The form lists preferred long-acting products (e.g., certain fentanyl and morphine ER formulations and Butrans®) and requires additional documentation and attestations when non-preferred long-acting opioids are requested.

Key terms and formulary notes

MME — morphine milligram equivalents definition

DefinitionMorphine milligram equivalents (MME) — the cumulative opioid dose expressed as the morphine-equivalent milligrams per day used to assess opioid intensity

Use on formPA form asks for member's Active Daily MME from the PMP to determine management requirements and PA triggers

Threshold applicationCumulative opioid prescriptions exceeding 90 MME/day trigger PA and additional attestations

Preferred long-acting opioids

Preferred long-acting opioid examplesButrans® transdermal patch; fentanyl 12, 25, 50, 75, and 100 mcg patches; morphine sulfate ER tablets

Preferred short-acting opioid examples (context)codeine/APAP; hydrocodone/APAP; hydrocodone/ibuprofen; hydromorphone; morphine IR; oxycodone IR; oxycodone/APAP; tramadol HCl 50 mg; tramadol HCl/APAP

Non-preferred product noteNon-preferred long-acting products (e.g., Avinza®, Kadian®, Embeda®) require documentation of trial and failure of 2 different preferred products