Centene opioid prior auth policy update

Coverage Criteria

Initial: Cancer, Sickle Cell Disease, or Palliative Care

Covered when ALL of the following are met

Cancer/Sickle Cell/Palliative initial criteria: 1) Prescribed for pain associated with cancer OR sickle cell disease OR palliative care (hospice/terminal); 2) Member meets one of: (a) request is for cancer treatment in a state with regulations against oncology step therapy (see Appendix E) OR (b) member has failed an adequate trial of two formulary short-acting opioid analgesics that do not require prior authorization, dosed around the clock, unless clinically significant adverse effects occurred or all are contraindicated;

Approval duration: 12 months

Initial: Short-Acting Agents (<14-day supply)

Covered when ALL of the following are met

Short-acting <14 days initial criteria: 1) Prescribed for treatment of pain unrelated to cancer, palliative care, or sickle cell disease; 2) For Ohio requests only: total opioid dose does not exceed 80 MME/day unless member is stable on >80 MME/day; 3) Member has failed an adequate trial of two formulary short-acting opioid analgesics that do not require prior authorization, dosed around the clock, unless clinically significant adverse effects occurred or all are contraindicated; 4) Provider will initiate a dose taper and documentation of taper attempts (if applicable) is provided; 5) For Ohio requests only: if opioid is prescribed concomitantly with a benzodiazepine, provider documents acknowledgment of combined use and either prescribes for short term (<3 months) or discontinues concurrent benzodiazepine within 3 months;

Approval duration: 14 days

Initial: Long-Acting Agents or Requests Exceeding Supply Thresholds

Covered when ALL of the following are met

Long-acting or >14-day supply initial criteria: 1) Prescribed for treatment of pain unrelated to cancer, palliative care, or sickle cell disease; 2) For short-acting agent requests: either failure of >=2 non-opioid/ancillary treatments (e.g., NSAIDs, acetaminophen, anticonvulsants, antidepressants) OR prescribed agent is a formulary short-acting agent that does not require prior authorization; 3) For long-acting agent requests: failure of an adequate trial of two formulary short-acting opioids dosed around the clock AND failure of an adequate trial of two formulary long-acting agents when required; 4) Louisiana-specific: if request is for an abuse-deterrent formulation, substitution shall not be made to an ER medication lacking defined abuse-deterrent properties;

Approval duration: long-acting 12 months; short-acting for request duration (usually up to 3 months)

Initial: Diabetic Peripheral Neuropathy (Nucynta ER)

Covered when ALL of the following are met

Nucynta ER DPN initial criteria: 1) Request is for Nucynta ER; 2) Diagnosis of diabetic peripheral neuropathy; 3) Age >= 18 years; 4) Failure of a formulary tricyclic antidepressant (e.g., amitriptyline, nortriptyline, imipramine) at up to maximally indicated doses unless contraindicated or intolerant; 5) Failure of gabapentin at >= 1,800 mg/day unless contraindicated or intolerant; 6) Failure of a formulary SNRI (e.g., duloxetine, venlafaxine) at up to maximally indicated doses unless contraindicated or intolerant; 7) Requested dose does not exceed 500 mg per day;500 mg/day

Approval duration: 6 months or duration of request (whichever is less)

Continued Therapy: Cancer, Sickle Cell Disease, Palliative Care

Covered when ALL of the following are met

Continued therapy cancer/palliative: 1) Member is currently receiving the prescribed agent via the Centene benefit or previously met initial approval criteria; 2) Provider submits documentation supporting continued medical need for the agent (medical justification, chart notes);

Approval duration: 12 months

Continued Therapy: Short-Acting Agents

Covered when ALL of the following are met

Continued short-acting <14 days: 1) Member is currently receiving the medication via Centene benefit or previously met initial approval criteria; 2) Member meets continuity-of-care provisions if applicable; 3) Dose reduction has occurred since previous approval OR a dose taper has been attempted within the past 6 months with reasons for taper failure provided (Ohio specifics regarding <=80 MME/day apply); 4) For Ohio requests only: if concomitant benzodiazepine use exists, documentation supports attempts to discontinue combination therapy in the last 3 months;

Approval duration: 14 days

Continued Therapy: Long-Acting Agents or Requests Exceeding Supply Thresholds

Covered when ALL of the following are met

Continued long-acting or large supply: 1) Member is currently receiving the medication via Centene benefit or previously met initial approval criteria; 2) Member has received >14-day supply within 28 days OR >28-day supply within 90 days; 3) Provider submits medical justification and documentation of recent follow-up (within last 6 months); 4) Provider attests they reviewed the treatment plan with the member and assessed risks/benefits; 5) For Ohio requests only: total opioid dose does not exceed 80 MME/day unless member is stable on higher doses or taper attempts are documented; 6) For Ohio requests only: if concomitant benzodiazepine use exists, documentation that discontinuation was attempted in last 3 months;

Approval durations: short-acting up to 3 months or duration of request; long-acting 12 months

Continued Therapy: Nucynta ER (DPN)

Covered when ALL of the following are met

Nucynta ER continued criteria: 1) Member is currently receiving Nucynta ER for diabetic peripheral neuropathy or previously met initial approval criteria; 2) Provider submits medical justification and recent follow-up notes demonstrating continued need; 3) If a dose increase is requested, the new dose does not exceed 500 mg per day; 4) Provider attests they have reviewed the treatment plan and assessed risks and benefits of therapy;500 mg/day

Approval duration: 6 months or duration of request (whichever is less)

Continuation therapy — Nucynta ER (diabetic peripheral neuropathy)

Covered when ALL of the following are met:

Diabetic Peripheral Neuropathy continuation for Nucynta ER: 1) Request is for Nucynta ER; 2) Member is currently receiving Nucynta ER for diabetic peripheral neuropathy or has met initial approval criteria; 3) Member continues to need Nucynta ER as evidenced by provider-submitted medical justification (including but not limited to specified documentation); 4) Notes demonstrating follow-up with the member are provided; 5) If request is for a dose increase, new dose does not exceed 500 mg per day; 6) Attestation that provider has reviewed treatment plan and assessed risks/benefits;dose ceiling 500 mg/day

Approval duration: 6 months or duration of request (whichever is less)

For requests originating in Louisiana for an abuse‑deterrent formulation, substitution to an extended‑release product that does not have defined abuse‑deterrent properties is prohibited. This means when the prescriber requests an abuse‑deterrent formulation, the plan will not substitute a non‑ADF extended‑release opioid that lacks documented abuse‑deterrent technology.

Opioid therapies carry boxed warnings for potential for addiction, abuse, and misuse and are subject to the FDA Risk Evaluation and Mitigation Strategy (REMS). There is a risk of life‑threatening respiratory depression, accidental ingestion, and neonatal opioid withdrawal syndrome with intrauterine exposure. Concomitant use with benzodiazepines or other central nervous system depressants increases risk. Specific contraindications include significant respiratory depression, acute or severe bronchial asthma, and gastrointestinal obstruction including paralytic ileus.

Use of opioid agents is not appropriate when contraindications or boxed warnings are present (for example, significant respiratory depression, hypersensitivity to the active ingredient, or when REMS requirements cannot be met). For Nucynta ER specifically, concurrent or recent (within 14 days) use of monoamine oxidase inhibitors is a contraindication. Additionally, for long‑acting opioid requests in Louisiana, do not substitute a requested abuse‑deterrent formulation with a non‑ADF extended‑release product lacking defined abuse‑deterrent properties.

Coding and Dose Rules

Total opioid dose — MME thresholds

General thresholdTotal opioid dose does not exceed 80 MME per day (Ohio-specific requirement); members with a documented history of stability on >80 MME/day may be considered per Ohio language

Ohio exceptions for stabilityFor Ohio requests, members with a history of >7 days of therapy at >80 MME/day may be continued if documentation supports stability

Ohio documentation for >80 MME/dayIf requested dose is >80 MME/day for Ohio, an increase in dose must not have occurred since the previous approval and reasons for maintaining dose must be provided

Ohio taper requirementFor Ohio requests, a dose taper must have been attempted within the past 6 months (or provider will initiate a taper) with documentation of reasons for taper failure when applicable

Opioid oral MME conversion factors (Appendix C)

Oxycodone

Actions Required by Providers / Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Prior authorization (PA) is required for all formulary and short‑acting opioids that require PA and for any non‑formulary opioid requests.

PA required for all formulary and short‑acting opioids that have PA listed
PA required for any non‑formulary opioid requests

Step Therapy

Step Therapy Requirements

Step therapy requirements apply to most non‑oncology opioid requests. For non‑cancer, non‑palliative, non‑sickle cell indications, members must generally have failed trials of specified non‑opioid and/or short‑acting opioid agents prior to approval of long‑acting agents or certain supplies. Illinois HIM requests are exempt from these step therapy requirements per IL HB 5395 and Appendix E where state regulation prohibits step therapy in oncology settings.

Non‑cancer/palliative/sickle cell long‑acting requests: failure of two formulary short‑acting opioids dosed around the clock (unless contraindicated)

Conservative Treatment Requirements

Definitions

Morphine milligram equivalents (MME) — definition

TermMME (morphine milligram equivalents)

PurposeStandardized measure to compare opioid potency across agents by converting doses to morphine-equivalent milligrams

Reference locationDefined/abbreviated in Appendix A and used throughout dosing/threshold guidance in the policy

Morphine milligram equivalents — conversion context

Conversion contextAppendix C lists per-agent oral MME conversion factors used to calculate total daily MME for enforcement of dose ceilings and prior authorization criteria

Use in Ohio-specific rulesCalculated total MME determines compliance with Ohio thresholds (e.g., <=80 MME/day unless documented stability)

Background

Opioid analgesics exert their effect via opiate receptors and are indicated for management of moderate to severe pain. This policy separates coverage pathways for pain related to cancer, sickle cell disease, or palliative care from non‑cancer pain, and distinguishes short‑acting versus long‑acting agents with different prior authorization and duration rules. Prescribers should be aware of state‑specific provisions (for example, Illinois step therapy exemptions) and safety limits including boxed warnings, contraindications, and requirements to document prior trials of non‑opioid or formulary short‑acting agents where specified.

Revision History

2025-04-08added

Added bypassing of redirection when state regulations prohibit step therapy in certain oncology settings and added step therapy bypass for IL HIM per IL HB 5395.

2025-05-25added

Recorded approval adding step therapy bypass for IL HIM per IL HB 5395 (administrative approval date entry).

2025-06-29revised

Updated language to add IL HIM 5395 bypass specifically for diabetic peripheral neuropathy and removed 'do not apply to formulary agents requiring PA' from other IL HIM 5395 bypass statements.

OpenPayer

Opioid Analgesics prior authorization and coverage criteria

Coverage Criteria

Coding and Dose Rules

Actions Required by Providers / Prior Authorization

Conservative Treatment Requirements

Definitions

Background

Revision History