CurrentCignaPolicy N/A

Opioids - Long-Acting Products Prior Authorization Policy

Defines Cigna's prior authorization requirements and medical necessity criteria for coverage of long-acting (LA) opioid prescription products for members under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyOpioids - Long-Acting Products Prior Authorization Policy

Policy CodePolicy N/A

Change TypeCriteria additions and removal

Effective DateN/A

Next Review Date01/29/2025

Key ActionSubmit prior authorization with documentation that non-opioid therapies are optimized, PDMP review completed, naloxone and toxicology needs assessed, and hematology involvement documented for sickle cell patients.

SourceLink

POLICY UPDATE CHANGES

Added new approval diagnosis of sickle cell disease with requirement that medication be prescribed by or in consultation with a hematologist.

Added criterion that the need for a naloxone prescription has been assessed and naloxone has been ordered, if necessary.

Added criterion that the need for periodic toxicology testing has been assessed and ordered, if necessary.

Methadone products were removed from this policy and moved to a separate Methadone PA policy.

10+listed long-acting opioid products included

1 yearstandard approval duration

CII/CIII/CIVcontrolled substance schedules

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Coverage Criteria for Long-Acting Opioids

Initial approval (FDA-approved indications and supportive uses)

Covered when ONE of the following is met (approve for 1 year):

Covered Indications

Chronic severe pain group (D): i. Patient is not opioid-naïve; AND ii. According to the prescriber, non-opioid therapies have been optimized and are being used in conjunction with opioid therapy; AND iii. According to the prescriber, patient's history of controlled substance prescriptions has been checked using the state prescription drug monitoring program (PDMP); AND iv. According to the prescriber, risks (e.g., addiction, overdose) and realistic benefits of opioid therapy have been discussed with the patient; AND v. According to the prescriber, treatment plan (including goals for pain and function) is in place and reassessments (including pain levels and function) are scheduled at regular intervals; AND vi. According to the prescriber, need for a naloxone prescription has been assessed and naloxone has been ordered, if necessary; AND vii. According to the prescriber, need for periodic toxicology testing has been assessed and ordered, if necessary.

Fentanyl transdermal specific criteria

Fentanyl transdermal products covered when:

Fentanyl transdermal indication: Patient has a cancer diagnosis requiring daily, around-the-clock, long-term opioid treatment

Approve for 1 year for this indication.

Long-acting opioids are considered experimental, investigational, or unproven for any use outside the specified covered indications. The policy explicitly lists such uses as not covered, and reserves approval only for the indications defined elsewhere in this policy (e.g., cancer-related pain, hospice/palliative care, sickle cell disease with hematology involvement, or chronic severe pain meeting all prescriber attestations).

The policy states that the use of extended-release/long-acting (LA) opioids for acute pain is not medically necessary. This aligns with CDC guidance which recommends clinicians should not prescribe LA opioids for acute pain because of their longer half-lives and prolonged effects (including increased risk of respiratory depression).

Product & Coding Information

Included long-acting opioid products (non-exhaustive)mixed

buprenorphine	Belbuca buccal film; Butrans transdermal patch (buprenorphine products)
fentanyl transdermal	Fentanyl transdermal patch (generic only)
hydrocodone ER	Hydrocodone extended-release capsules/tablets (e.g., Hysingla ER)
hydromorphone ER	Hydromorphone extended-release tablets (e.g., generic/Exalgo)
morphine sulfate ER	Morphine sulfate extended-release capsules/tablets (e.g., MS Contin)
oxycodone ER	Oxycodone extended-release capsules/tablets (e.g., Xtampza ER, OxyContin)
oxymorphone ER	Oxymorphone extended-release tablets (generic only)
tapentadol ER	Tapentadol extended-release tablets (e.g., Nucynta ER)
tramadol ER	Tramadol extended-release capsules/tablets (e.g., Conzip, generic)

inv-06: Approval duration

Standard approval durationApprove for 1 year for covered indications

Applies toAll long-acting opioid approvals provided for the duration noted (see policy)

Fentanyl transdermalFentanyl transdermal approvals are covered under specific fentanyl criteria (approve for 1 year for cancer indication)

Prescriber Requirements and Action Items

Prior Authorization

Prior Authorization Required

Prior authorization is required for long-acting opioids. Approvals are granted for 1 year for covered indications. Because of the specialized skills required for evaluation and diagnosis of patients with sickle cell disease and monitoring required for adverse events and long-term efficacy, approval requires that LA opioids be prescribed by or in consultation with a hematologist for patients with this diagnosis.

All long-acting opioids (except fentanyl transdermal products) require prior authorization.
Approvals are provided for 1 year for covered FDA-approved indications or other uses with supportive evidence.
For sickle cell disease, prescriber must be the hematologist or document consultation with a hematologist.

Step Therapy

Conservative Therapy Expectation

Prescribers must have optimized non-opioid pharmacologic and nonpharmacologic therapies before initiating long-acting opioid therapy and should continue to use these therapies in conjunction with opioids. Examples of non-opioid therapies include nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, selected antiseizure medications (e.g., pregabalin, gabapentin), topical agents (capsaicin, lidocaine), physical therapy, exercise therapy, weight loss, cognitive behavioral therapy, and other noninvasive interventions (e.g., yoga, acupuncture, spinal manipulation).

Conservative Treatment & Non-Opioid Optimization

Prescriber must attest non-opioid therapies have been optimized and are being used in conjunction with opioid therapy.

Prescriber must attest that the following non-opioid and nonpharmacologic therapies have been optimized and are being used in conjunction with opioid therapy:

Required prescriber attestations

Nonpharmacologic therapies maximized as appropriate (examples: exercise, physical therapy, weight loss, cognitive behavioral therapy).
Non-opioid pharmacologic therapies optimized (examples: NSAIDs, tricyclic antidepressants, SNRIs/duloxetine, selected antiseizure medications, topical agents).
Patient is not opioid-naïve when initiating a long-acting opioid for chronic severe pain.
Prescriber has checked the state prescription drug monitoring program (PDMP) for the patient's controlled substance history.

Key Definitions

inv-13: Long-acting (LA) opioid

DefinitionExtended‑release or long‑duration opioid formulations intended for daily, around‑the‑clock, long‑term opioid analgesia

Common included products (non‑exhaustive)Buprenorphine, fentanyl (transdermal), hydrocodone ER, hydromorphone ER, morphine sulfate ER, oxycodone ER, oxymorphone ER, tapentadol ER, tramadol ER

Controlled substance schedulesMost LA opioids are Schedule II; buprenorphine products are Schedule III; tramadol-containing products are Schedule IV

inv-14: Opioid-naïve

DefinitionPatient who has not previously been exposed to opioids such that initiation with a long‑acting opioid is not recommended by the policy and referenced guidelines

Policy implication — initiation

Authorization Duration & Frequency

inv-16: LA opioid prescription authorization

Authorization durationLA opioid prescriptions approved for a period of 1 year

Frequency limit entryApproval duration listed as the frequency limit period for LA opioid prescription authorization

Applies to covered indications1‑year approvals apply when policy criteria are met (e.g., cancer, hospice, sickle cell with hematology involvement, or chronic severe pain meeting all prescriber attestations)

Imaging Requirements

Note

Imaging requirements — none specified

No specific imaging requirements are listed in the policy for LA opioid authorization; document clinical justification per usual standards if imaging is relevant to the diagnosis.

Policy does not specify imaging prerequisites for LA opioid coverage.

Not Covered / Exclusions

Not covered: Long-acting opioids for acute pain. The policy explicitly excludes LA opioids when used to treat acute pain and notes such use is considered experimental/investigational and therefore may be denied.

Background

Long-acting opioids are intended for management of severe, persistent pain requiring daily, around-the-clock, long-term opioid treatment when alternatives are inadequate. Guideline recommendations emphasize maximizing nonpharmacologic and nonopioid therapies and reserving LA opioids for patients who have failed or cannot tolerate those options; initiation in opioid‑naïve patients is not recommended. The policy therefore restricts coverage to defined serious indications and requires prescriber documentation that conservative measures have been optimized.