CurrentColorado Rocky Mountain Health PlansPolicy N/A

Analgesics, Opioid Short-Acting prior authorization

This Pennsylvania prior authorization form and guidance governs requests and renewals for short-acting opioid analgesics for Pennsylvania Medical Assistance beneficiaries and specifies documentation and clinical criteria prescribers must provide to obtain coverage.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAnalgesics, Opioid Short-Acting prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 6, 2025

Next Review DateN/A

Key ActionFax a completed PA form and supporting clinical documentation (including diagnosis, DX code, and PDMP query where required) to the DHS Pharmacy Division for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-6numbered clinical requirement sections for initial requests

12 moUDS interval for renewals (at least every)

3 morecent UDS required after

PAjurisdiction

Coverage Criteria for Short‑Acting Opioid Analgesics

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Initial Therapy

Covered when ALL of the following are met for initial requests (criteria vary by specific agent):

General initial criteria: Has documentation of pain caused by a medical condition that is moderate to severe and not migraine in type (does NOT apply to nasal butorphanol); tried and failed or has a contraindication or intolerance to appropriate non-opioid analgesics (acetaminophen; duloxetine; gabapentinoids such as gabapentin or pregabalin; NSAIDs; tricyclic antidepressants); and was assessed for potential risk of opioid misuse or opioid use disorder by the prescriber.

Applies to all Analgesics, Opioid Short-Acting

Transmucosal fentanyl specific: Patient has a diagnosis of cancer; is opioid-tolerant (defined as taking at least morphine 60 mg/day, transdermal fentanyl 25 mcg/hour, oxycodone 30 mg/day, oral hydromorphone 8 mg/day, or an equianalgesic dose of another opioid for one week or longer); is prescribed transmucosal fentanyl by a specialist certified in pain medicine, oncology, or hospice and palliative medicine; and has a contraindication to preferred short-acting opioid agents.

Transmucosal fentanyl-specific requirements

Nasal butorphanol for migraine: Patient is not opioid-tolerant; is being treated for migraine; is prescribed nasal butorphanol by a neurologist or headache specialist certified in headache medicine; and has tried and failed or has a contraindication or intolerance to listed abortive agents (acetaminophen; NSAIDs; triptans; dihydroergotamine) and to listed preventive agents (anticonvulsants; beta blockers; botulinum toxins; CGRP inhibitors; calcium channel blockers; SNRIs; tricyclic antidepressants).

Migraine-specific nasal butorphanol requirements

Nasal butorphanol for non-migraine pain: Is prescribed nasal butorphanol by a specialist certified in neurology, pain medicine, oncology, or hospice and palliative care medicine; and has tried and failed or has a contraindication or intolerance to at least 3 unrelated (different opioid ingredient) preferred short-acting opioid agents.

Non-migraine nasal butorphanol requirement

Non-preferred short-acting opioid agents: For a non-preferred Analgesic, Opioid Short-Acting, the beneficiary tried and failed or has a contraindication or intolerance to preferred Analgesics, Opioid Short-Acting per the Preferred Drug List.

Step therapy requirement for non-preferred agents

Concurrent buprenorphine or Vivitrol: If the beneficiary has a concurrent prescription for a buprenorphine agent for OUD or for Vivitrol (naltrexone extended-release), both prescriptions are prescribed by the same prescriber OR prescriptions are by different prescribers and all prescribers are aware of the other prescriptions.

Coordination of care requirement

Concurrent benzodiazepine: If the beneficiary has a concurrent benzodiazepine prescription, document that the benzodiazepine is being tapered, or the opioid is being tapered, or that concomitant use is medically necessary; or indicate that the beneficiary is not taking a benzodiazepine.

Safety requirement for concomitant benzodiazepine use

Certain clinical states are handled outside the standard PA pathway and must be submitted to DHS for special handling. Active cancer, sickle cell with crisis, and neonatal abstinence syndrome require submission to DHS rather than routine PA processing. Similarly, beneficiaries who are receiving palliative care or hospice services, or who are being treated post-operatively or following a traumatic injury, should have their requests submitted to DHS. These exceptions apply across requests for all short-acting opioid analgesics and are specified on the PA form instructions.

Use and coverage include agent-specific limitations and exclusionary notes. For example, most short-acting opioid approvals require the pain to be not migraine in type; however, this restriction does not apply to nasal butorphanol for migraine, which has its own specialized criteria. Transmucosal fentanyl is restricted to beneficiaries with a diagnosis of cancer, who are opioid-tolerant, and when prescribed by a specialist certified in pain medicine, oncology, or hospice and palliative medicine. All requests must document trials and failures or contraindications to appropriate non-opioid analgesics and include assessment of opioid misuse risk.

Required Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Analgesics, Opioid Short‑Acting. Submit a completed PA form (see form effective 2025-01-06) with all required supporting documentation; fax to the Pharmacy PA Call Center at 1-866-940-7328 or contact 1-800-310-6826.

Completed PA form fields including prescriber name, contact, NPI, state license #, beneficiary name, ID#, DOB, diagnosis and DX code, requested drug name/strength/formulation/directions, quantity per fill, requested duration, and prescriber signature.
Required clinical documentation: diagnosis documentation, evidence of trials or contraindications to preferred agents, specialty certification when required, urine drug screen results (at least every 12 months) when applicable, and documentation of assessment for opioid misuse/OUD risk.

Step Therapy

Step Therapy / Preferred Agent Trials — Documentation Required

Documentation must explicitly show trials and failures of preferred agents or specific contraindications/intolerances, or the request may be denied. For transmucosal fentanyl and certain specialty-prescribed agents, include specialist certification. If concurrent buprenorphine for OUD or Vivitrol is present, document same‑prescriber or that all prescribers are aware.

For transmucosal fentanyl: documentation of cancer diagnosis, opioid-tolerance (definition provided on form), and prescription by a certified specialist in pain medicine, oncology, or hospice/palliative medicine, or contraindication to preferred agents.
For nasal butorphanol (migraine): documentation that patient is not opioid-tolerant, treatment for migraine, prescription by neurologist/headache specialist certified in headache medicine, and trial/failure or contraindication to listed abortive and preventive medications.
For non-migraine non-preferred opioids: documentation of trial and failure or contraindication/intolerance to preferred Analgesics, Opioid Short‑Acting (or at least 3 unrelated preferred short-acting opioids for non-migraine nonpreferred use).

Denial Risk

Documentation and Prior Therapy Gaps — Denial Risk

Failure to provide required submission items or to document prior therapy trials, contraindications, specialist certification, or opioid-misuse assessment may result in denial. Ensure UDS results, pain assessment details (cause, severity, non-migraine specification where applicable), and proof of trials of non-opioid analgesics are included.

Include diagnosis code (DX code) on the PA form.
Include copies of prior therapy records showing dates, agents tried, and reasons for failure/intolerance or documentation of contraindications.
Include specialty certification letter or credentials when required (e.g., pain medicine, oncology, hospice/palliative, neurology/headache specialist).
Include recent urine drug screen results and documentation of opioid misuse/OUD risk assessment when applicable.
If beneficiary has concurrent benzodiazepine, document tapering or medical necessity, or indicate not applicable.

OpenPayer

Analgesics, Opioid Short-Acting prior authorization

Coverage Criteria for Short‑Acting Opioid Analgesics

Required Provider Actions and Submission Requirements

Conservative Treatment / Trial Requirements

Key Definitions

Not Covered / Exclusions

Background and Purpose