CurrentColorado Rocky Mountain Health PlansPolicy N/A

Opioid long-acting prior authorization (Chronic Pain)

Form governing prior authorization requests for long-acting opioid analgesics for beneficiaries with chronic non-cancer pain; used by prescribers requesting coverage or reauthorization and by the payer to document required clinical information.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOpioid long-acting prior authorization (Chronic Pain)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed beneficiary and prescriber identification, drug details, clinical justification for doses >90 MME, prior trial documentation (short-acting within 45 days for initials), and prescriber attestations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 mgMME daily threshold

45 daysShort-acting trial lookback

2Preferred-agent trials required

4 weeksChronic pain duration

Coverage Criteria

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inv-01: Authorization criteria

Covered when ALL of the following are met

Baseline requirements: Beneficiary identification and prescriber information provided; drug name, strength, quantity, and requested length of therapy specified; for chronic non-cancer pain, documented chronic pain duration (>= 4 weeks).

Refer to Clinical Information questions 1-2 and Drug/Beneficiary sections of the form.

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

Clinical Information question 1

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

Clinical Information question 3 and 3a–3b

Initial authorization additional requirement: For initial authorizations, documentation that a short-acting opioid analgesic was tried in the past 45 days or an explanation for why it was not tried must be provided.45 days

Clinical Information questions 4 and 4a–4b

Non-preferred product justification: For non-preferred long-acting opioid products, document either: (1) history within the past year of trials of two preferred long-acting opioid analgesics at an equal/equivalent dose, or (2) a documented contraindication or allergy to the preferred product(s).2 preferred trials in past year or documented contraindication

Non-Preferred Products questions 9–10

Prescriber attestations: Prescriber must attest to review of the N.C. Medical Board statement on controlled substances, adherence to opioid management components (evaluation, treatment plan/contract, informed consent, periodic review, specialist consultation as appropriate), and to checking the NC Controlled Substance Reporting System (PDMP).

Clinical Information questions 5–7; signature required

Patients with a diagnosis of malignant cancer or pain due to neoplasm are exempt from the prior authorization requirement for long‑acting opioid therapy. This exemption is captured directly on the clinical information form and should be documented when applicable to expedite coverage decisions.

Coding & Thresholds

Daily opioid morphine milligram equivalent threshold

Daily MME threshold> 90 mg morphine equivalent per day

Action if exceededProvide diagnosis/reason and duration (questions 3a and 3b on form).

Assessment contextApplies to requested daily dose in combination with other concurrent opioids (question 3).

Initial trial period for short-acting opioid

Initial short-acting opioid trial windowTrial of a short-acting opioid within the prior 45 days is required for initial authorization (question 4a).

If not triedIf no short-acting trial, provider must explain why (question 4b).

Applies toInitial authorization requests only (question 4).

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for long-acting opioid analgesics unless the patient has malignant cancer or pain due to neoplasm (exempt). Completed beneficiary and prescriber identification, drug name/strength/quantity, and length of therapy must be submitted with the request.

Beneficiary and Prescriber Identification (see form fields for name, ID, DOB, gender, prescriber NPI, and contact).
Drug name, strength, quantity per 30 days, and selected length of therapy (up to 30/60/90/120/180/365 days or other).

Step Therapy

Preferred-Agent Trial Requirement

For non-preferred long-acting opioid products, documentation that the patient has tried two preferred long-acting opioids within the past year at an equal or equivalent dose is required to justify use of a non-preferred product. Alternatively, document a contraindication or allergy to the preferred agents.

Document trials of two preferred long-acting opioids within the past year OR list contraindication/allergy to preferred products.
Provide names, doses, and dates of preferred-agent trials.

Documentation Required

Required Submission Elements

Completed beneficiary and prescriber identification, detailed drug information, and clinical answers (including chronic pain duration, prior short-acting opioid trial, adherence to controlled-substance monitoring, and signature) are required. Prescriber signature and date are mandatory.

Beneficiary: last name, first name, beneficiary ID, DOB, gender.
Prescriber: NPI, requester contact name and phone.
Drug: name, strength, quantity per 30 days, length of therapy selection.
Clinical: cancer/neoplasm exemption, chronic pain duration (>=4 weeks), initial vs reauthorization, prior short-acting opioid trial within 45 days, adherence to controlled-substance guidelines, review of PDMP/controlled-substance registry.
Prescriber signature and date (mandatory).

Denial Risk

Documentation & Dosing Exceedance Risk

Requests for daily opioid doses exceeding 90 mg morphine-equivalent require explicit justification of diagnosis and the duration (days supply) the beneficiary will exceed the 90 mg/day threshold. Lack of required documentation or failure to justify doses above the limit may result in denial or the need for reauthorization.

If total daily opioid dose > 90 mg morphine-equivalent, provide: beneficiary diagnosis/reason for exceeding limit and duration (days supply) of exceedance.
Answer questions 3, 3a, and 3b on the clinical form; missing responses may delay or result in denial.
For initial requests, indicate whether a trial of a short-acting opioid was used within the past 45 days and provide explanation if not.

Conservative Treatment & Trial Documentation

inv-12: Document trials or contraindications — 45 days (short-acting trial); 1 year lookback for preferred long-acting trials

Document trials or contraindications

Short-acting opioid trial for initial requests: For initial authorization requests, document that the beneficiary tried a short-acting opioid analgesic within the prior 45 days; if not, provide an explanation.trial within prior 45 days

Clinical Information question 4 and 4a–4b

Preferred long-acting agent trials for non-preferred products: When prescribing a non-preferred long-acting opioid, document either: (A) a history within the past year of trials of two preferred long-acting opioid analgesics at an equal or equivalent dose, or (B) a documented contraindication or allergy to the preferred product(s).1 year lookback for two preferred trials

Non-Preferred Products questions 9–10

Background

This form is used to manage long‑acting opioid therapy for beneficiaries with chronic pain when such treatment is being considered or continued. It distinguishes chronic non‑cancer pain—defined on the form as a pain syndrome of at least four (4) weeks—from cancer‑related pain, which is exempt from prior authorization. The form captures required elements including diagnosis, daily opioid dose and justification when the dose exceeds 90 mg morphine equivalent per day, whether an initial trial of a short‑acting opioid occurred within the prior 45 days, and prescriber attestations to state and CDC opioid prescribing guidance and PDMP review.

Definitions

Chronic pain

Definition of chronic painPain syndrome of at least four (4) weeks duration as asked on the form (question 2).

DocumentationProvider must indicate 'Yes' or 'No' to chronic pain duration on the form (question 2).

RelevanceUsed to determine applicability of prior authorization for long-acting opioids for chronic non-cancer pain.

Dose threshold

Dose threshold requiring justificationA daily opioid dose greater than 90 mg morphine equivalent requires additional justification (provide diagnosis and duration per questions 3a and 3b).

Form questionsQuestions 3, 3a and 3b capture whether dose exceeds 90 mg MME and request diagnosis/reason and duration if so.

Applies toRequested daily dose in combination with other concurrent opioids (question 3).