CurrentCignaPolicy N/A

Opioids - Morphine Milligram Equivalent (200) Drug Quantity Management Policy

Defines Cigna's drug quantity management rules for opioid prescriptions calculated in morphine milligram equivalents (MME), including approval criteria for requests that would exceed 200 MME/day. Applies to health benefit plans administered by Cigna companies.

Policy Summary

PayerCigna

PolicyOpioids - Morphine Milligram Equivalent (200) Drug Quantity Management Policy

Policy CodePolicy N/A

Change TypeMaterial criteria additions

Effective Date

Next Review DateMar 4, 2025

Key ActionIf a prescription will cause the patient to exceed 200 MME/day, submit for prior authorization; approvals may be provided for up to 1 year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

New override criteria were added to approve if the patient has a diagnosis of sickle cell disease and the medication is prescribed by or in consultation with a hematologist.

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

Point-of-sale alerts noted to manage opioid quantity distribution prior to utilization management edits.

200primary threshold that triggers this policy

90related safety edit (POS)

≤600upper approval band

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Coverage and Approval Criteria

MME-based approval criteria

Covered when the following criteria are met for the specified MME ranges

>200 and ≤600 MME/day approvals

A - Cancer: Patient has a cancer diagnosis
B - Hospice/palliative: Patient is in a hospice program, end-of-life care, or palliative care
C - Sickle cell disease (both): Patient has a diagnosis of sickle cell disease AND medication is being prescribed by or in consultation with a hematologist
D - Comprehensive criteria: All of: i. Non-opioid therapies have been optimized and are being used in conjunction with opioid therapy; ii. Patient's history of controlled substance prescriptions checked using the state PDMP; iii. Risks and realistic benefits of opioid therapy discussed with the patient; iv. Patient has a treatment plan or pain contract with reassessments scheduled at regular intervals; v. Need for a naloxone prescription assessed and naloxone ordered if necessary; vi. Need for periodic toxicology testing assessed and ordered if necessary

>600 MME/day approvals

A - Cancer: Patient has a cancer diagnosis
B - Hospice/palliative: Patient is in a hospice program, end-of-life care, or palliative care
C - Sickle cell disease (both): Patient has a diagnosis of sickle cell disease AND medication is being prescribed by or in consultation with a hematologist
D - Comprehensive criteria: All of: i. Non-opioid therapies have been optimized and are being used in conjunction with opioid therapy; ii. Patient's history of controlled substance prescriptions checked using the state PDMP; iii. Risks and realistic benefits of opioid therapy discussed with the patient; iv. Patient has a treatment plan or pain contract with reassessments scheduled at regular intervals [documentation required]; v. Need for a naloxone prescription assessed and naloxone ordered if necessary; vi. Need for periodic toxicology testing assessed and ordered if necessary

General policy operation: MME calculated per claim using conversion factors; cumulative daily MME determines whether threshold exceeded; point-of-sale alerts manage quantity prior to utilization management edits

Opioid cough and cold products are excluded from the calculation of morphine milligram equivalents (MME) used by this Drug Quantity Management program. The policy calculates cumulative daily MME from prescription claims using conversion factors for each opioid product; exclusions for cough and cold formulations mean those products are not included in the MME total that triggers program thresholds.

Any request for an opioid quantity that does not meet the policy's specified approval criteria is considered not medically necessary. The MME (200) DQM policy defines approved quantities and requires that exceptions meet the listed clinical criteria; requests outside those criteria will be denied.

Thresholds and Coding References

MME thresholds - inv-04: MME thresholds — 90, 200, 600

Point-of-service safety edit90 MME/day (CMS-recommended POS safety edit)

Policy trigger threshold200 MME/day (primary threshold that triggers this policy; claims causing >200 MME/day will reject at point of sale and require additional coverage determination)

Documentation threshold600 MME/day (documentation required for approval of additional quantities over 600 MME/day)

Provider Responsibilities and Authorization Flow

Prior Authorization

Prior Authorization Required for >200 MME/day

Prior authorization required when a prescription will cause a patient to exceed a cumulative daily MME of 200. Point-of-sale claims will reject at >200 MME/day; additional coverage is determined per the policy criteria. All approvals are provided for up to 1 year unless otherwise noted.

Point-of-sale alerts occur prior to Utilization Management edits.
Approvals provided for up to 1 year unless otherwise noted.

Prior Authorization

Requirements Before Higher‑Dose Approval

Before approving doses >200 and ≤600 MME/day or >600 MME/day under the exception criteria, the prescriber must ensure and document that non-opioid therapies have been optimized and are being used in conjunction with opioid therapy; the patient’s controlled substance history has been checked using the state PDMP; risks and realistic benefits of opioid therapy have been discussed with the patient; the patient has a treatment plan or pain contract with scheduled reassessments; naloxone need has been assessed and ordered if necessary; and need for periodic toxicology testing has been assessed and ordered if necessary.

Background and Rationale

Morphine milligram equivalent (MME) is used to assess opioid-associated risk by converting opioid prescriptions to a common morphine equivalent and summing the patient’s cumulative daily dose. Higher daily MME correlates with increased risk of adverse events, and regulatory guidance supports point-of-service safety edits to limit exposure. This policy references a 90 MME point-of-service safety edit and uses 200 MME/day as the primary policy trigger; approved exceptions and documentation requirements apply at higher bands (for example, approvals up to 600 MME/day and separate documentation requirements for doses > 600 MME/day). Point-of-sale alerts manage opioid quantity distribution before utilization management edits are applied.

Key Definitions

MME — Morphine milligram equivalent definition - inv-10

DefinitionMorphine milligram equivalent (MME): a calculated value converting an opioid medication dose to an equivalent amount of morphine using an appropriate conversion factor for the opioid product, used to assess cumulative daily opioid dose and associated risk.

Calculation contextMME is calculated for each opioid prescription claim using the appropriate conversion factor; cumulative daily MME is then determined to assess whether thresholds are exceeded.

ExclusionsOpioid cough and cold products are excluded from MME calculations.

Use in policyMME calculation is used to determine if a prescription will cause the patient to exceed the 200 MME/day threshold, which triggers claim rejection and further review.