CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization for opioid agents (Florida Medicaid form)

Form and clinical requirements for prior authorization of short-acting and long-acting opioid medications for Florida Medicaid recipients; affects prescribers requesting opioid coverage and continuation authorizations.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization for opioid agents (Florida Medicaid form)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required documentation (UDS within 90 days, medication trial history, MME calculation, and supporting records) and retain records for five years.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 monthslength per approval

7 dayspost-op short-acting limit

90 daysUDS recency

5 yrsdocumentation retention

MME > 90MME denial threshold (treatment-naïve)

Coverage criteria for opioid prior authorization

Initial and continuation opioid therapy criteria

Covered when ALL of the following are met:

Form and documentation: Completed PA form with patient and prescriber identifiers, drug name/strength/dose/directions, diagnosis, prescriber specialty

Form must be complete; incomplete forms may be returned

Prior trials and step therapy: For short-acting opioids, document trial and failure of listed alternatives (e.g., baclofen, NSAIDs, tricyclic antidepressants, pregabalin, duloxetine) prior to prescribing; if requesting a non-preferred agent, document trial and failure of preferred agents including medication names, strength, frequency, length of trials, and rationale for discontinuation

Medical records documenting trials are required

Safety checks: Prescriber must review the PDMP prior to prescribing as required by Florida statute, submit UDS within the past 90 days for new chronic pain patients and for continuation of ongoing therapy, have a signed patient-prescriber pain management agreement for chronic pain patients, and document the next scheduled office visit

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization for opioid agents (Florida Medicaid form)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Key coding thresholds and tests

inv-04: Daily MME threshold for treatment‑naïve patients

Daily MME thresholdTreatment‑naïve patients: maximum allowable daily MME = 90 (requests with MME > 90 will not be approved)

Calculation requirementPrescriber must calculate and report the daily morphine milligram equivalent (MME) on the PA form

Dose increase documentationIf requesting an increase, calculate the new daily MME and provide medical justification

inv-05: UDS recency requirement (urine drug screen within 90 days)

UDS recency requirementSubmission of a urine drug screen (UDS) within the past 90 days is required for new chronic pain patients and for ongoing therapy

Prescriber responsibilityPrescriber must order and review the UDS prior to initiation and for continuation of opioid therapy

Exception documentationIf UDS not submitted, prescriber must explain why on the form

Requirements and actions for prescribers

Prior Authorization
Prior Authorization Required
Prior authorization is required for short-acting and/or long-acting opioids. Approvals are issued for up to 3 months. Incomplete forms may be returned.
Length of approval: up to 3 months
Incomplete or partially completed forms may be returned

Prior Authorization
Long-Acting Opioid Prerequisite
Long-acting opioids require supporting documentation of a minimum two-month trial of short-acting opioid use prior to approval.
Document minimum two-month trial of short-acting opioid use
Long-acting opioids indicated for chronic, around-the-clock moderate to severe pain

Step Therapy
Trial of Preferred Agents Required
If requesting a non-preferred agent, document trial and failure of preferred agents. Include medication names, strengths, frequency, length of trials, and rationale for discontinuation in the submitted medical records.
Trial and failure of preferred agents required for non-preferred requests
List medication name, strength, frequency, length of trial, and reason stopped
Submit supporting medical records documenting trials

Documentation Required
Form Completion and Clinical Documentation
Complete the PA form in full and submit with required clinical documentation. An incomplete form may be returned. Required form fields include patient identifiers, prescriber information (including NPI and specialty), drug name/strength/dose/directions, diagnosis, and whether short-acting, long-acting, or both are requested. For prior opioid therapy, include trial history and dates.
Recipient full name, Medicaid ID, DOB
Prescriber's full name, NPI, phone and fax, specialty
Drug name, strength, dose, directions, diagnosis
Indicate short-acting, long-acting, or both
Document prior medication trials and dates

Documentation Required
Required Records and Retention
Submit all copies of relevant medical records (diagnostic evaluations, recent chart notes) and the most recent related labs. Providers must retain copies of all documentation for five years. For patients with chronic pain, submission of a urine drug screen within the past 90 days is required. Calculate and document the daily morphine milligram equivalent (MME) of prescribed medications; requests for treatment‑naïve patients exceeding 90 MME will not be approved.
Submit medical records and recent labs; retain documentation for five years
UDS within past 90 days required for chronic pain patients
Document daily MME; requests >90 MME for treatment‑naïve patients will be denied

Definitions and role descriptions

inv-13: Long-acting opioids — indication and documentation requirements

IndicationLong-acting opioids are indicated for patients with chronic, moderate to severe pain who require around-the-clock opioid analgesics

Minimum prior trialSupporting documentation of a minimum two-month trial of short-acting opioid use is required before long-acting opioids are approved

Documentation expectedMedical records documenting trials (names, strength, frequency, length, rationale for discontinuation) must be submitted

inv-14: Treatment‑naïve patient MME threshold definition

DefinitionTreatment‑naïve patient: a patient for whom the requested daily MME exceeds the threshold for initiation — PA will not be approved when requested daily MME > 90

Operational thresholdThreshold used to determine approval for initial therapy: <= 90 daily MME for treatment‑naïve patients

Provider actionIf treatment‑naïve patient requires >90 MME, provide clinical justification — note: PA will not be approved as stated

Required conservative treatment and trials

Document prior medication trials and rationale for discontinuation

Required documentation of prior medication trials: List all prior medication trials (names, strength, frequency, length of trial) and provide the clinical rationale for discontinuation for each agent trialed (including non-opioid and adjuvant therapies such as baclofen, NSAIDs, tricyclic antidepressants, pregabalin, duloxetine)

Medical records documenting trials are required and must be submitted with the PA request

Document trial of short-acting opioids — 2 months trial requirement

Minimum short-acting opioid trial for long-acting requests: For requests for long-acting opioid agents, document a minimum two-month trial of short-acting opioid use prior to approval2 months

Supporting documentation of the trial duration must be provided

Approval length and supply limits

inv-17: Opioid prescription authorization — up to 3 months per approval

Authorization lengthPrior authorization approvals are issued for up to 3 months per authorization

Form completenessPA form must be completed in full; incomplete forms may be returned and delay approval

Applies toApplies to short-acting and long-acting opioid agents requiring PA

inv-18: Post-operative short-acting opioid supply — 7 days without medical justification

Post‑operative limitAny requests for post-operative short-acting opioids cannot exceed a 7-day supply without medical justification

Medical justificationRequests exceeding 7 days must include documented medical justification in the medical records submitted for review

Documentation requirementMedical records documenting trials and rationale must be provided when applicable

Policy background and intent

The PA form enforces multiple safety checks that must be documented before approval. Prescribers are required to review the state Prescription Drug Monitoring Program (PDMP) prior to prescribing, document the review on the form, and include a signed patient–prescriber pain management agreement for chronic pain when applicable.

Urine drug screening (UDS) results must be ordered, reviewed, and submitted with the request; the form requires a recent UDS for new chronic pain patients and for ongoing therapy (the brief specifies UDS within the prior 90 days as the recency standard).

Providers must submit supporting medical records that document prior medication trials (names, strengths, frequency, duration, and rationale for discontinuation), include the calculated daily MME, and document the next scheduled visit. Medical records and related labs must be retained and are requested for review as part of the authorization process.