Cigna opioid therapy Coverage & Prior Auth

Coverage Criteria for Opioid Analgesics

Immediate-release opioid analgesic medical necessity

Immediate-release opioid analgesics are medically necessary when ONE of the following is met:

Immediate-release: cancer/sickle cell/end-of-life: Documented diagnosis of active cancer treatment (receiving antineoplastic/antitumor therapy), end-of-life care (including hospice/palliative), OR sickle cell disease.

Non-Covered Product Criteria must also be met where applicable.

Immediate-release: acute pain (<90 days): Management of acute pain (<90 days) when ALL of the following are met: A. Attestation that the history of controlled substance prescriptions has been checked using the state PDMP; B. ONE of: i) for acute dental pain, attestation that an initial regimen exceeding 3 days is medically necessary; ii) for acute non-dental pain, attestation that an initial regimen exceeding 7 days is medically necessary; C. Non-Covered Product Criteria is met.<90 days

Immediate-release: chronic pain (>90 days): Management of chronic pain (>90 days) when ALL of the following are met: A. Failure, contraindication, or intolerance to nonopioid pharmacologic therapies intended to treat pain; B. Attestation that the history of controlled substance prescriptions has been checked using the state PDMP; C. Attestation that opioids will be prescribed in accordance with current clinical practice guidelines AND that an assessment of risks, harms, and goals consistent with an opioid agreement (or comprehensive treatment plan) has been undertaken; D. Non-Covered Product Criteria is met.>90 days

Extended-release opioid analgesic medical necessity

Extended-release opioid analgesics are medically necessary when ONE of the following is met:

Extended-release: cancer/sickle cell/end-of-life: Documented diagnosis of active cancer treatment (receiving antineoplastic/antitumor therapy), end-of-life care (including hospice/palliative), OR sickle cell disease.

Non-Covered Product Criteria must also be met where applicable.

Extended-release: long-term daily therapy: Diagnosis of pain severe enough to require daily, around-the-clock, long-term opioid treatment when ALL of the following are met: A. Failure, contraindication, or intolerance to a minimum one-week trial of immediate-release opioids; B. Failure, contraindication, or intolerance to nonopioid pharmacologic therapies intended to treat pain; C. Attestation that the history of controlled substance prescriptions has been checked using the state PDMP; D. Documentation that opioids will be prescribed in accordance with current clinical practice guidelines AND that an assessment of risks, harms, and goals consistent with an opioid agreement (or comprehensive treatment plan) has been undertaken; E. Non-Covered Product Criteria is met.>=1 week trial of IR

Methadone and fentanyl transdermal patches — medical necessity options

Methadone and fentanyl transdermal patches — medical necessity options:

Methadone/fentanyl: cancer/sickle cell/end-of-life: Documented diagnosis of active cancer treatment (receiving antineoplastic/antitumor therapy), end-of-life care (including hospice/palliative), OR sickle cell disease.

Methadone/fentanyl: chronic daily therapy with opioid tolerance: ALL of the following: A. Diagnosis of pain severe enough to require daily, around-the-clock, long-term opioid treatment; B. Failure, contraindication, or intolerance to a minimum one-week trial of immediate-release opioids; C. Opioid tolerant (required daily dosage for pain management exceeds 60 MME); D. Alternative treatment options are ineffective, not tolerated, or inadequate; E. Attestation that the history of controlled substance prescriptions has been checked using the state PDMP; F. Documentation that opioids will be prescribed in accordance with current clinical practice guidelines AND that an assessment of risks, harms, and goals consistent with an opioid agreement (or comprehensive treatment plan) has been undertaken; G. Medication prescribed by, or in consultation with, a board-certified pain management specialist.>60 MME

High-dose opioid (>120 and >200 MME) medical necessity

High-dose opioid therapy (by total daily MME) — medical necessity conditions:

>120 MME: Either documented diagnosis of active cancer treatment, end-of-life care, OR sickle cell disease; OR ALL of the following: A. Failure, contraindication, or intolerance to nonopioid pharmacologic therapies intended to treat pain; B. Attestation that the history of controlled substance prescriptions has been checked using the state PDMP; C. Documentation that opioids will be prescribed in accordance with current clinical practice guidelines AND that an assessment of risks, harms, and goals consistent with an opioid agreement (or comprehensive treatment plan) has been undertaken; D. Consideration of additional precautions intended to reduce risk of serious harm (for example, education and provision of naloxone); E. Quarterly reassessment of opioid therapy benefits and risks specific to diagnosis and treatment goals; F. Medication prescribed by, or in consultation with, a board-certified pain management specialist.>120 MME

>200 MME: Either documented diagnosis of active cancer treatment, end-of-life care, OR sickle cell disease; OR ALL of the following: A. Failure, contraindication, or intolerance to nonopioid pharmacologic therapies intended to treat pain; B. Attestation that the history of controlled substance prescriptions has been checked using the state PDMP; C. Documentation that opioids will be prescribed in accordance with current clinical practice guidelines AND that an assessment of risks, harms, and goals consistent with an opioid agreement (or comprehensive treatment plan) has been undertaken; D. Quarterly reassessment of opioid therapy benefits and risks specific to diagnosis and treatment goals; E. Consideration of additional precautions intended to reduce risk of serious harm (for example, education and provision of naloxone); F. The provider has performed an individualized behavioral health screening to assess risks and benefits of the opioid dose (for example, PHQ-9, GAD-7, PC-PTSD); G. The provider has screened for substance abuse risk to assess risks and benefits of the opioid dose (for example, DIRE, ORT, PDUQ, PMQ); H. Medication prescribed by, or in consultation with, a board-certified pain management specialist.

Injectable opioid analgesic medical necessity

Injectable opioid analgesics are medically necessary when ONE of the following is met:

Injectable: cancer/sickle cell/end-of-life: Documented diagnosis of active cancer treatment (receiving antineoplastic/antitumor therapy), end-of-life care (including hospice/palliative), OR sickle cell disease.

Injectable: other indications: ALL of the following: A. Documented pathology (objective basis for the pain complaint); B. Failure of at least six (6) months of noninvasive pain management, including active rehabilitative exercises; C. Opioid tolerant (required daily dosage for pain management exceeds 60 MME); D. Alternative opioid formulations (oral, suppository, transdermal) are ineffective, not tolerated, or inadequate; E. Attestation that the history of controlled substance prescriptions has been checked using the state PDMP; F. Prescribed by, or in coordination with, a board-certified pain management specialist.>=6 months noninvasive therapy; >60 MME

Resources for MME calculation in Appendix 4.

Reauthorization criteria

Reauthorization

Reauthorization: Continued use requires that initial medical necessity criteria continue to be met AND there is documentation of beneficial response.

Initial and continuation opioid therapy coverage criteria

Covered when ALL of the following are met

Core requirements: 1) Nonpharmacologic and nonopioid pharmacologic therapies have been optimized or are inappropriate for the patient; 2) For long-acting opioids: pain is severe, continuous, and requires daily around-the-clock long-term opioid therapy; 3) For pediatric use, only specific products with pediatric indications (e.g., OxyContin for ages 11-18) are used when applicable; 4) Clinician has documented treatment goals, discussed risks/benefits, reviewed PDMP data, and considered risk mitigation strategies (for example, offering naloxone and consideration of toxicology testing).

Logic follows CDC 2022 and ASH 2020 guidance.

This Coverage Policy applies to health benefit plans administered by Cigna companies. Certain Cigna companies and/or lines of business may provide only utilization review and not make coverage determinations; in those situations the member's plan documents and drug benefit list may supersede or further limit coverage. The Non‑Covered Product Table and plan/drug‑list specific rules also apply.

Per guideline recommendations, clinicians should not initiate long‑acting (LA) opioids for opioid‑naïve patients and should not prescribe LA opioids for intermittent use. LA opioids are intended for severe, continuous pain that requires daily, around‑the‑clock long‑term opioid therapy; prescribers should prioritize the lowest effective dose of immediate‑release opioids for the expected duration of acute pain and maximize nonopioid pharmacologic and nonpharmacologic therapies when appropriate.

Use of long‑acting opioid formulations for patients who are opioid‑naïve or for intermittent pain is considered not medically necessary under guideline‑based recommendations cited in this policy. LA opioids should be reserved for patients with severe, continuous pain after appropriate evaluation, treatment goals, risk assessment, and documentation of alternatives tried or deemed inappropriate.

Prior Authorization, Documentation, and Prescriber Requirements

Prior Authorization

Prior Authorization Required and Coding/Claims

Prior authorization is required for opioid analgesics when coverage depends on meeting the Medical Necessity Criteria in this policy. Claims submitted without covered diagnosis or procedure codes consistent with the applicable benefit plan and this policy will be denied. Providers must use the most appropriate and current billing codes when submitting requests and claims.

Submit prior authorization (PA) requests with supporting clinical documentation and appropriate ICD-10/CPT/NDC codes.
Claims lacking covered diagnosis/procedure codes will be denied.

Prior Authorization

Prior Authorization Specifics for Long‑Acting Opioids

For long-acting (extended-release or transdermal) opioid requests, prior authorization requires justification that long-acting therapy is necessary relative to alternatives and that step requirements have been met. LA opioids should not be initiated in opioid‑naïve patients and should not be prescribed for intermittent use; they are reserved for severe, continuous pain.

Document failure, contraindication, or intolerance to a minimum one‑week trial of immediate‑release opioids when indicated.

Nonopioid and Conservative Therapy Requirements

Failure of noninvasive management including active rehab

Failure of noninvasive management including active rehabilitative exercises is required for certain therapies when the following duration is met:

Duration requirement: Failure of at least six (6) months of noninvasive pain management, including active rehabilitative exercises, is required before considering injectable opioid analgesic therapy.6 months

Applies to injectable opioid analgesics per criteria.

Trial of immediate-release opioids

Trial of immediate-release opioids is required prior to certain long-acting opioid therapies:

IR opioid trial: Minimum one-week (>=1 week) trial of immediate-release opioids is required (failure, contraindication, or intolerance) before initiating extended-release opioids, methadone, or fentanyl transdermal patches for chronic daily therapy.

Codes, Dose Thresholds, and Conversion Factors

Referenced prescribing informationmixed

N/A	Prescribing information and references listed; no specific billing codes provided in this part of the document.

Opioid dose thresholds (MME)

Opioid tolerant threshold>= 60 MME (required daily dosage for pain management exceeds 60 MME)

>120 MMETotal daily opioid dose >120 MME — additional precautions required (e.g., naloxone education/provision, quarterly reassessment, specialist involvement)

>200 MMETotal daily opioid dose >200 MME — higher safeguards required including behavioral health screening and substance abuse risk screening plus specialist consultation

Total daily MME calculation and example

Calculation methodAdd total daily milligrams of each opioid, multiply each opioid total by its conversion factor, then sum results to obtain total daily MME

Example — oxycodone

Key Definitions

Opioid tolerant

DefinitionOpioid tolerant: required daily dosage for pain management exceeds 60 morphine milligram equivalents (MME)

Context for long-acting opioidsOpioid tolerance is a required condition for long-acting formulations in chronic daily therapy criteria

Use in injectable opioidsInjectable opioid criteria also require opioid tolerance (≥60 MME) for non-cancer indications

Long-acting vs Immediate-release opioids

Long-acting (extended-release/transdermal)Formulations intended for daily, around-the-clock, long-term opioid treatment (e.g., ER or transdermal products such as fentanyl patches)

Immediate-release (short-acting)Formulations for management of pain requiring an opioid but not intended for long-term continuous use; often required as a trial prior to ER products

Not Covered

Initiation of long‑acting opioids in opioid‑naïve patients and prescribing LA opioids for intermittent pain are not covered in accordance with the guideline recommendations referenced in this policy. Coverage determinations remain subject to applicable plan documents and the Non‑Covered Product Table for the member's plan and drug list.

Background and Scope

Long‑acting opioid formulations (extended‑release and transdermal) are indicated for management of pain severe enough to require daily, around‑the‑clock, long‑term opioid treatment when alternatives are inadequate. Short‑acting (immediate‑release) opioids are intended for pain severe enough to require an opioid but not for continuous long‑term therapy. Methadone has distinct indications including treatment of opioid use disorder when dispensed through certified opioid treatment programs.

Frequency Limits

Frequency limits

Frequency limits specifiedNot specified in this document segment

ImplicationNo procedure- or product-specific frequency limits are provided in the shown policy excerpt

Where to checkRefer to plan-specific documents or appendices for any frequency limits not included here

Revision History and Policy Changes

2026-03-01removalLatest

Opium Tincture was removed from Appendix 1.

2025-09-15clarification

Clarified Methadone use for treatment of Opioid Use Disorder (OUD).

2025-05-15addition

OpenPayer

Opioid Therapy for Employer Group Benefit Plans