CurrentColorado Rocky Mountain Health PlansPolicy N/A

Opioid prior authorization form for long-acting opioids

Form-based prior authorization requirements for long-acting opioid analgesics for beneficiaries in North Carolina; governs prescriber attestations, clinical questions, dose limits, and documentation required to obtain coverage.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOpioid prior authorization form for long-acting opioids

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the opioid prior authorization form, provide NPI and signature, document diagnosis and justify doses >90 mg MME/day, and list trials of two preferred long-acting opioids or document contraindication for non-preferred products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 mgMME threshold

2Preferred trials required

Sickle CellSpecial diagnosis asked

Malignant cancerCancer exemption

Coverage and Authorization Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization criteria for long-acting opioids

Covered when ALL of the following form conditions are met as applicable:

Form completion and prescriber attestations: Prescriber must complete beneficiary and prescriber identification, indicate whether the request is initial or a reauthorization (attach documentation for continuation if reauthorization), sign the form, and attest to adherence to the N.C. Medical Board statement and review of the CDC guideline where applicable.

chunks 3,4

Exemption for malignant cancer/neoplasm: If the patient has a diagnosis of malignant cancer or pain due to neoplasm, the patient is exempt from the prior authorization requirement.

chunk 3

Dose limit and justification: If the requested combined daily opioid dose with other opioids exceeds 90 mg morphine equivalent per day, the prescriber must provide the beneficiary's diagnosis/reason for exceeding the limit and the duration (days' supply) the beneficiary will exceed the 90 mg MME/day threshold.>90 mg MME/day requires justification

chunk 3

Safety and monitoring attestations: Prescriber must confirm review of the NC Controlled Substance Reporting System and attest adherence to clinical safeguards including complete beneficiary evaluation, treatment plan and informed consent, periodic review, and specialist consultation as medically appropriate.

chunk 3

Step therapy for non-preferred long-acting opioids: For requests for non-preferred long-acting opioid products, document either (A) trials within the past year of two preferred long-acting opioid analgesics at equal or equivalent doses to the non-preferred product OR (B) a documented contraindication or allergy to ingredients in the preferred products. Prescriber must list the prior preferred products or the contraindication/allergy.two prior preferred products within 1 year or documented contraindication/allergy

chunk 4

Patients with malignant cancer or pain due to a neoplasm are exempt from the prior authorization requirement. The form explicitly asks whether the patient has a diagnosis of malignant cancer or pain due to neoplasm and states that answering "Yes" makes the patient exempt from prior authorization.

Prescriber Actions, Documentation, and Step Therapy

Prior Authorization

Prior Authorization Required

Prior Authorization Required: A prior authorization is required for opioid prescriptions. The prescriber must complete and submit the opioid prior authorization form and supply all requested clinical information and justifications on the form. Requests for initial authorizations and reauthorizations must indicate which is being requested and include supporting documentation for continuation of therapy when applicable.

Complete the official opioid prior authorization form
Indicate if this is an initial authorization or a reauthorization; for reauthorization, attach documentation supporting continued opioid treatment and current plan of care
If daily opioid dose (combined with other opioids) exceeds 90 mg morphine milligram equivalents (MME), provide diagnosis, reason for exceeding the limit, and planned duration (days supply) of the exceedance
Attest that prescriber reviewed applicable guidelines (state medical board statement, CDC opioid prescribing guideline) and checked the state controlled substance reporting system

Step Therapy

Step Therapy for Non‑Preferred Long‑Acting Opioids

Step therapy applies for non‑preferred long-acting opioid products. For a non-preferred long-acting opioid to be approved, documentation must show a trial and failure (or contraindication/allergy) of two preferred long-acting opioid analgesics at doses equivalent to the requested non-preferred product within the past 12 months.

Documented trials of two preferred long-acting opioids within the past year at doses equal or equivalent to the requested non-preferred product
If unable to trial preferred products, provide contraindication or allergy documentation and list the specific agents

Documentation Required

Required Form Documentation and Attestations

Required form fields and attestations must be completed on the prior authorization form. Missing prescriber identity fields or omitted attestations may result in denial.

Prescriber identity: Prescribing Provider NPI, Prescriber signature and date (signature mandatory)
Requester contact: name, phone number, extension (if applicable)
Clinical questions: cancer/neoplasm exemption, sickle cell disease, initial vs reauthorization indicator
Dose justification: diagnosis and reason for exceeding 90 MME/day and duration (days supply) if applicable
Attestations: review of state medical board controlled substances statement, adherence to components of opioid management (evaluation, treatment plan/contract, informed consent, periodic review, specialist consultation), and review of CDC prescribing guideline

Denial Risk

Denial Risk for Incomplete Documentation

Denial Risk for Incomplete Documentation: Requests may be denied if required documentation, attestations, or an applicable exemption (e.g., malignant cancer/neoplasm) are not provided. Failure to document prior trials for step therapy, to justify doses >90 MME/day, or to include prescriber signature and required contact/NPI information increases risk of denial.

Requests lacking the completed opioid prior authorization form or required fields may be denied
Omitted documentation of two preferred long-acting opioid trials for non‑preferred products may result in denial
Failure to provide justification for doses exceeding 90 MME/day and duration may lead to denial
If an exemption is claimed (e.g., cancer/neoplasm), supporting documentation must be supplied to avoid denial

Definitions and Exemptions

Exempt from prior authorization

Exemption criteriaBeneficiary with malignant cancer or pain due to neoplasm is exempt from the prior authorization requirement

How exemption is identifiedForm asks: 'Does the patient have a diagnosis of malignant cancer or pain due to neoplasm?' with Yes/No response

Effect of exemptionIf 'Yes', prior authorization is not required for the requested therapy

Dose exceedance documentation

Documentation required when >90 mg MME/dayPrescriber must supply the beneficiary's diagnosis and reason for exceeding the 90 mg MME/day limit

Duration requiredPrescriber must provide the duration (days supply) the beneficiary will exceed the 90 mg MME/day limit

Context on assessmentThese questions are required when the requested combined daily opioid dose exceeds 90 mg morphine or equivalent

OpenPayer

Opioid prior authorization form for long-acting opioids

Coverage and Authorization Criteria

Dose Thresholds and Coding Notes

Prescriber Actions, Documentation, and Step Therapy

Definitions and Exemptions

Background