Cigna Opioid Therapy Coverage Update

Coverage Criteria for Opioid Therapies

inv-01: Immediate‑Release Opioid Medical Necessity

Immediate‑release opioid analgesics are considered medically necessary when the individual meets ONE of the following:

Immediate‑release opioids - Category I: Documented diagnosis of active cancer treatment (receiving antineoplastic/antitumor therapy), end‑of‑life care (including hospice/palliative care), OR sickle cell disease. Non‑Covered Product Criteria is met.

Immediate‑release opioids - Acute pain: For acute pain (<90 days): A. Attestation that the history of controlled substance prescriptions has been checked using the state prescription drug monitoring program (PDMP); B. ONE of: i. For acute dental pain: attestation that an initial treatment regimen exceeding 3 days is medically necessary; ii. For acute non‑dental pain: attestation that an initial treatment regimen exceeding 7 days is medically necessary; C. Non‑Covered Product Criteria is met.<90 days

Immediate‑release opioids - Chronic pain: For chronic pain (>90 days): 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 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

inv-02: Extended‑Release Opioid Medical Necessity

Extended‑release opioid analgesics are considered medically necessary when the individual meets ONE of the following:

Extended‑release opioids - Category I: Documented diagnosis of active cancer treatment (receiving antineoplastic/antitumor therapy), end‑of‑life care (including hospice/palliative care), OR sickle cell disease. Non‑Covered Product Criteria is met.

Extended‑release opioids - Chronic severe pain: Diagnosis of pain severe enough to require daily, around‑the‑clock, long‑term opioid treatment AND: 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.daily long‑term treatment

inv-03: Methadone and Fentanyl Patch Medical Necessity

Methadone and fentanyl transdermal patches:

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

Methadone/Fentanyl - Chronic severe pain with opioid tolerance: For non‑cancer severe chronic pain: 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 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

inv-04: High‑Dose Opioid Criteria

High‑dose opioid management (by total daily MME):

>120 MME: For total daily opioid dose exceeding 120 MME: either A. Documented diagnosis of active cancer treatment, end‑of‑life care, OR sickle cell disease; OR B. ALL of: failure, contraindication, or intolerance to nonopioid pharmacologic therapies intended to treat pain; attestation that the history of controlled substance prescriptions has been checked using the PDMP; 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; consideration of additional precautions to reduce risk (eg, education and provision of naloxone); quarterly reassessment of opioid therapy; and medication prescribed by, or in consultation with, a board‑certified pain management specialist.>120 MME

>200 MME: For total daily opioid dose exceeding 200 MME: either A. Documented diagnosis of active cancer treatment, end‑of‑life care, OR sickle cell disease; OR B. ALL of: failure, contraindication, or intolerance to nonopioid pharmacologic therapies; PDMP attestation; documentation of opioid agreement and guideline‑concordant prescribing; quarterly reassessment of benefits and risks; consideration of additional precautions (eg, naloxone); individualized behavioral health screening (eg, PHQ‑9, GAD‑7, PC‑PTSD); screening for substance abuse risk (eg, DIRE, ORT, PDUQ, PMQ); and medication prescribed by, or in consultation with, a board‑certified pain management specialist.>200 MME

inv-05: Injectable Opioid Medical Necessity

Injectable opioid analgesics are considered medically necessary when ONE of the following applies:

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

Injectable opioids - Non‑cancer severe chronic pain: ALL of: 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 treatment options (oral, suppository or transdermal opioid therapy) are ineffective, not tolerated, or inadequate; E. Attestation that the history of controlled substance prescriptions has been checked using the PDMP; F. Prescribed by, or prescribed in coordination with, a board‑certified pain management specialist.>=6 months conservative care

inv-06: General prescribing criteria

Covered when guidance-based clinical criteria are met and documented

General opioid initiation and continuation: Clinician has maximized nonpharmacologic and nonopioid pharmacologic therapies as appropriate; discussed realistic benefits and known risks of opioid therapy with the patient; established treatment goals for pain and function before starting ongoing opioid therapy; documented PDMP review; evaluated risk for opioid‑related harms and incorporated mitigation strategies (for example, offering naloxone and reviewing interactions); and prescribed the lowest effective dosage for the shortest duration needed for acute pain.

Follow CDC 2022 guideline principles

inv-07: Long-acting opioid criteria

Additional requirements for long-acting opioids

Long-acting opioid use: Do not initiate long‑acting (LA) opioids in opioid‑naïve patients; do not prescribe LA opioids for intermittent use; reserve LA opioids for severe, continuous pain and document justification. Calculate and document total daily MME when applicable and document rationale for LA opioid initiation.

Coverage of products listed as non‑covered in the Immediate‑Release, Extended‑Release, or other Non‑Covered Product tables is restricted unless the specific product‑level criteria are met as described in those tables. Receipt of sample product does not satisfy any criteria requirements for coverage. Product‑specific exceptions (for example, brand vs generic formulation differences) and preferred product requirements are documented in the Non‑Covered Product Criteria / Preferred Product Requirement tables and must be met for coverage consideration.

Long‑acting (LA) opioids should be reserved for patients with severe, continuous pain. Clinicians should not initiate LA opioids in opioid‑naïve patients and should not prescribe LA opioids for intermittent use. Justification for LA opioid therapy and documentation that alternative, less risky options were considered must be provided when seeking prior authorization.

Recent policy revisions have updated preferred product requirements and clarified certain statements in the criteria language. Examples include adding preferred product criteria for selected Dilaudid strengths and Percocet, clarifying Methadone use for OUD, removing Opium Tincture from Appendix 1, and revising the immediate‑release criteria wording effective 05/01/2026. These changes may be reflected in product tables and preferred product lists elsewhere in the policy.

Dose Thresholds and MME Coding

Opioid daily dose thresholds (MME)

Opioid tolerantRequired daily dosage for pain management exceeds 60 morphine milligram equivalents (MME).

High‑dose thresholdTotal daily opioid dose >120 MME — additional precautions required (eg, naloxone consideration, quarterly reassessment, specialist involvement).

Very high‑dose thresholdTotal daily opioid dose >200 MME — requires behavioral health screening, substance abuse risk screening, and board‑certified pain specialist involvement/consultation in addition to precautions above.

MME calculation example

Example total daily MMETotal daily MME = 75 MME (40 mg oxycodone/day → 40 x 1.5 = 60 MME; 15 mg hydrocodone/day → 15 x 1 = 15 MME; 60 + 15 = 75 MME).

Step 1 — compute totalsCalculate total daily milligram amount for each opioid (eg, 20 mg oxycodone twice daily = 40 mg oxycodone; 5 mg hydrocodone TID = 15 mg hydrocodone).

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Prior authorization is required when coverage is subject to medical necessity criteria for immediate‑release, extended‑release/long‑acting, and injectable opioid analgesics. Requests for long‑acting (LA) opioids must justify need (severe, continuous pain), and LA opioids should not be initiated in opioid‑naïve patients. Methadone for opioid use disorder as part of an opioid treatment program is covered without prior authorization.

Applies to immediate‑release, extended‑release/LA, and injectable opioid analgesics
LA opioids reserved for severe, continuous pain; avoid initiating in opioid‑naïve patients
Methadone for OUD in opioid treatment programs: no prior authorization required

Step Therapy

Step Therapy / Trials Required

Step therapy is required prior to approving many extended‑release/long‑acting opioid products. For chronic pain, documentation must show failure, contraindication, or intolerance to nonopioid pharmacologic therapies and, for most LA products, a trial of immediate‑release opioids (minimum one week) when indicated by the product‑specific criteria.

Conservative Care and Trial Requirements

inv-27: Failure of at least 6 months of noninvasive pain management

Failure of at least six months of noninvasive pain management is required for certain advanced therapies:

>= 6 months conservative care: Failure of at least six (6) months of noninvasive pain management, including active rehabilitative exercises, must be documented prior to consideration of injectable opioid analgesics.>=6 months

inv-28: Trial of immediate‑release opioids for at least one week

Trial of immediate‑release opioids is required before extended‑release formulations:

>= 1 week IR opioid trial: Documentation of failure, contraindication, or intolerance to a minimum one‑week trial of immediate‑release opioids is required prior to initiation of extended‑release opioid therapy (including methadone and transdermal fentanyl where applicable).>=1 week

Imaging and Testing Requirements

Prior Authorization

Provide objective pathology when requesting injectable opioids

Injectable opioid requests must include documentation of objective pathology (an objective basis for the pain complaint) to support medical necessity in addition to other required elements.

Injectable opioids also require failure of ≥6 months of noninvasive pain management, opioid tolerance (>60 MME), and specialist involvement as applicable

Note

Consider toxicology testing and review PDMP data; imaging not specifically required

When prescribing opioids for subacute or chronic pain, consider toxicology testing and review PDMP data; the policy does not specify imaging requirements for opioid prescribing in this window.

Consider benefits and risks of toxicology testing to assess prescribed and nonprescribed controlled substances
PDMP review attestation is required in multiple medical necessity nodes

Background and Scope

Long‑acting and short‑acting opioid analgesics are indicated when pain is severe enough to require opioid treatment and alternative options (nonopioid pharmacologic and nonpharmacologic therapies) are inadequate. Clinicians should discuss realistic benefits and risks with patients, establish treatment goals for pain and function before initiating ongoing opioid therapy, use the lowest effective dosage of immediate‑release opioids for no longer than needed, and periodically reassess benefits and risks during continued therapy.

Definitions

Opioid tolerant

DefinitionOpioid tolerant is defined as required daily dosage for pain management that exceeds 60 morphine milligram equivalents (MME).

Context — LA opioidsOpioid tolerance (›60 MME) is required for extended‑release opioid eligibility except for cancer, end‑of‑life, or sickle cell disease categories.

Chronic pain

DefinitionChronic pain is defined as pain lasting more than 90 days.

Policy implicationChronic pain criteria trigger requirements: failure/intolerance to nonopioid therapies, PDMP check, opioid agreement, and Non‑Covered Product Criteria.

Example useChronic pain determination used to assess eligibility for both immediate‑release and extended‑release opioid criteria sets.

Products and Services Not Covered

Products listed in the Immediate‑Release, Extended‑Release, and other Non‑Covered Product tables are not covered unless the product‑specific criteria in those tables are satisfied. For certain branded products (for example, specific Dilaudid strengths and formulations), coverage requires meeting the preferred product or product‑specific exception criteria such as documented trial of the bioequivalent generic and a prescriber attestation that an inactive ingredient difference causes a clinically significant allergy or adverse reaction. These product‑level rules and any recent preferred product updates must be met to obtain coverage.

Revision History and Policy Changes

2026-05-01Annual RevisionLatest

Updated immediate-release criteria wording by removing the phrase 'in an opioid naïve individual' from the immediate-release criteria statement.

2026-03-01Selected Revision

Removed Opium Tincture from Appendix 1.

2025-09-15Selected Revision

OpenPayer

Opioid Therapy for Employer Group Benefit Plans