CurrentColorado Rocky Mountain Health PlansPolicy N/A

Greater-than-34-day retail opioid supply authorization

Policy governing authorization for retail opioid prescriptions exceeding a 34-day supply when the member's plan allows longer supplies; affects prescribers, pharmacies, and prior authorization staff for Colorado Rocky Mountain Health Plans members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyGreater-than-34-day retail opioid supply authorization

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective Date8/1/2025

Next Review DateN/A

Key ActionSubmit prior authorization with documented diagnosis and rationale that the member requires a greater-than-one-month opioid supply.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

34-daythreshold for retail opioid supply

12 monthsauthorization duration

All opioidsscope of medications

2018-2025program review history

Coverage 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.

Initial and ongoing approval

Covered when BOTH of the following are met:

Greater-than-34-day retail opioid supply approval: 1) The member requires a greater than one month supply of opioid medications; 2) Document the diagnosis associated with the need for pain management.Authorization issued up to the plan allowance for days' supply for 12 months.

Authorization will be issued for plans that allow a greater-than-34-day supply at retail up to the plan allowance of days' supply for 12 months.

This policy does not change existing clinical guidance that opioids are not first-line therapy for chronic pain and that clinicians should prescribe the lowest effective opioid dosage when initiating therapy. The program permits members whose plans allow retail fills longer than one month to receive supplies beyond 34 days up to the plan allowance, but it does not alter standard clinical caution about opioid initiation or routine use for chronic pain.

Requests that do not include a documented diagnosis supporting the need for pain management or that lack clinical rationale demonstrating the member requires a supply exceeding one month (greater than 34 days) will not meet coverage criteria and are subject to denial.

Coding and Definitions

Diagnosis codes referenced for automated approvalICD-10

ICD-10

Diagnosis codes may be used in automated approval and re-approval processes

Retail days' supply threshold

Retail days' supply threshold> 34 days

Effective date8/1/2025

Program nameSupply Limits - Greater than 34 day supply for opioids at retail

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for retail opioid supplies greater than a 34-day supply. Approvals will be issued up to the member's plan allowance for days' supply for up to 12 months.

>34-day retail opioid supplies require prior authorization
Approvals issued up to plan allowance for days' supply, for up to 12 months

Denial Risk

Denial Triggers

Requests will be denied if documentation does not establish that the member requires a supply greater than one month, or if other applicable denial conditions apply per plan terms and utilization management programs.

Denial if member does not require >1 month supply
Denial if supply limits or cumulative dose rules are exceeded
Denial if required plan/utilization criteria are not met

Documentation Required

Required Documentation

Submit clinical documentation that includes the member's diagnosis associated with the need for pain management and evidence that the member requires a supply greater than one month. Documentation may include relevant ICD-10 diagnosis codes, prior medication history, clinical notes, and rationale for extended days' supply.

Clinical diagnosis and supporting notes
Evidence member requires >1 month supply (treatment plan, prior fills)
Relevant ICD-10 diagnosis codes and prior medication history

Note

Interaction with Other Utilization Management Programs

Other clinical programs and utilization management processes may apply; approvals or reauthorizations may be based on prior claim/medication history, ICD-10 diagnosis codes, and automated claim logic. Supply limits, opioid cumulative dose reviews, and prior authorization/medical necessity rules may still be enforced.

Automated approval/re-approval based on claim history and ICD-10 codes
Supply limits and cumulative dose reviews may still apply
Policy not a substitute for other utilization management requirements

Background and Guidance

Background: The CDC recommends clinicians prescribe the lowest effective opioid dosage when initiating opioids and advises caution at any dosage. Clinical guidance further emphasizes that opioids are not first-line or routine therapy for chronic pain. This program aligns with those recommendations while providing an authorization pathway for members whose plans permit retail supplies greater than one month.

Definitions

Greater-than-34-day supply — definition

DefinitionGreater-than-34-day supply at retail: authorization for opioid prescriptions whose days' supply exceeds 34 days when the member's plan permits longer retail fills.

Applies toRetail pharmacy dispensing when member's plan allows >34-day supplies

Scope of medicationsIncludes all salt forms, single and combination products, short-acting and long-acting opioid formulations, brand and generic

Initial Therapy Criteria

Initial approval

Initial approval may be based on claims/diagnosis history

Initial approval pathways: UnitedHealthcare may approve initial requests based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic.

Use of automated approval varies by program and/or therapeutic class.

Continuation / Reauthorization Criteria

Reauthorization

Reauthorization rules

Reauthorization: Authorization may be reissued based on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic; when approved, reauthorization is up to the plan allowance for days' supply for 12 months.12 months

Automated re-approval processes may be used; authorization issued up to the plan allowance for days' supply for 12 months.

Step Therapy and Related Programs

Program note
Notwithstanding coverage criteria, other clinical/utilization management programs may apply (examples include automated approval based on prior claims/diagnosis history or claim logic, supply limits, opioid cumulative dose review, prior authorization/medical necessity, and prior authorization/new-to-therapy).

Quantity Limits

Opioids (all formulations)

Covered drug classOpioids (all formulations) — includes single/combo products, short-acting and long-acting, all salt forms

Quantity limitPlan allowance for days' supply (when plan permits >34-day retail fills)

Authorization pathwayPrior authorization and automated approvals may be used based on claims/diagnosis history and ICD-10 codes

Site of Care Applicability