CurrentColorado Rocky Mountain Health PlansPolicy N/A

Concurrent Drug Utilization Review (cDUR) program for opioids and controlled substances

Defines pharmacy point-of-sale and retrospective drug utilization review edits, messaging, and utilization management processes used to identify and manage potentially inappropriate opioid and controlled-substance prescribing and dispensing for plan members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyConcurrent Drug Utilization Review (cDUR) program for opioids and controlled substances

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization required to exceed point-of-sale quantity limits for initial short-acting opioid fills (e.g., >5-day supply for opioid‑naïve adults).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Point-of-sale + retrospectiveDUR types

90 MMEMME limit

5 daysInitial SAO limit

4 g/dayAPAP max

1 yearLock-in duration

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Concurrent DUR Program Criteria

cDUR program criteria

Program enforces the following point-of-sale and retrospective rules and prior authorization conditions:

Point-of-sale screening and alerts: Pharmacy claims are screened at point-of-service for drug-drug interactions (opioids with benzodiazepines, MAT drugs, sedative-hypnotics, skeletal muscle relaxants), duplicate long-acting opioids, and high-dose opioids; enhanced alerts are triggered for opioid use in pregnancy and for doses >50 MME recommending naloxone; pharmacists must address the clinical situation and enter appropriate NCPDP codes to receive an approved claim unless otherwise stated.see individual thresholds

From point-of-service edit descriptions.

Retrospective DUR (rDUR) triggers: Daily claim analyses identify members with multiple opioid prescriptions from multiple prescribers and/or multiple pharmacies, chronic early refill attempts, overlapping LAOs or SAOs, high daily opioid doses (including cumulative 90 MME), opioid overdose diagnosis with an opioid fill, overlapping opioid and MAT medications, overlapping opioid, muscle relaxant and benzodiazepine, or overlapping opioid and opioid potentiator; patient-specific information with a 4-month fill history is sent to prescribers.n/a

Used for outreach and interventions.

Utilization management limits: Prevents processing when cumulative opioid doses exceed 90 MME; enforces acetaminophen maximum of 4 g/day for combination opioid+APAP products; limits initial short-acting opioid (SAO) supply for opioid-naïve adults to a maximum 5-day supply at point-of-sale; pediatric SAO limits restrict to a maximum 5-day supply, maximum 180 units per 30 days, and maximum of 2 unique SAO products per 30 days; prior authorization is required to exceed these point-of-sale quantity limits.90 MME; 4 g APAP; 5-day supply; pediatric limits: 5 days; 180 units/30 days; 2 unique products

Includes prior authorization pathways for LAO and transmucosal fentanyl as specified.

Pharmacy lock-in criteria: Members filling opioids from multiple prescribers at multiple pharmacies may be selected for a pharmacy lock-in requiring use of a single pharmacy for 1 year (programs vary by state).multiple prescribers/pharmacies

State variation noted for lock-in programs.

Prior authorization for LAO and transmucosal fentanyl: Long-acting opioid (LAO) products require prior authorization with attestation of appropriate use and monitoring and documentation that the patient received 90 days of SAO treatment in the last 120 days for non-cancer pain; transmucosal fentanyl requires prior authorization with documentation of cancer-related pain and that the patient is already receiving opioids. There is a step requirement through two preferred short-acting fentanyl patches that requires cancer diagnosis or palliative care-related pain.90 days SAO in last 120 days (non-cancer pain)

Prior authorization documentation and step requirements are specified for certain products.

Prior authorization is not required for preferred overdose-prevention naloxone products. Examples cited in the program include generic naloxone injection and Narcan® Nasal Spray as preferred products that may be dispensed without prior authorization.

Codes, Limits, and Key Values

Point-of-sale billing codes (NCPDP)mixed

NCPDP point-of-sale codes

Pharmacist must enter appropriate NCPDP codes to receive approved claim where required

inv-04: Cumulative MME limit referenced in program

Cumulative MME limit90 MME — processing is prevented for cumulative opioid doses exceeding 90 MME at point-of-sale.

ContextApplied as a point-of-sale and retrospective threshold to identify high-dose opioid exposure.

Action on exceedanceClaims are prevented from processing and prescribers may be notified via rDUR communications.

inv-05: Acetaminophen daily maximum enforced for combination opioids

Acetaminophen daily maximum4 g per day for combination opioid + APAP products — prevents doses greater than 4 g/day.

ScopeApplied in retrospective DUR to limit combination opioid plus acetaminophen products.

Provider Requirements and Prior Authorization

Billing Rule

Point-of-sale Dose Limits

Point-of-sale cumulative dose limits are enforced at the pharmacy. Claims processing will be prevented when the member's cumulative opioid dose exceeds 90 milligram morphine equivalent (MME) per day. For combination opioid products containing acetaminophen, claims processing will also be prevented when the cumulative acetaminophen (APAP) dose would exceed 4 grams (4,000 mg) per day.

Opioid cumulative dose limit: 90 MME/day (point-of-sale)
Acetaminophen limit in combination products: 4 g/day (point-of-sale)

Documentation Required

Prior Authorization Documentation Requirements

Prior authorization requests for long-acting opioids (LAOs) and certain short-acting opioid exceptions must include clinical documentation attesting to appropriate use and monitoring. For non-cancer pain when requesting LAO therapy, documentation must show the patient received 90 days of short-acting opioid (SAO) treatment within the prior 120 days (or other reviewer-specified rationale where applicable). For transmucosal fentanyl products, prior authorization must document cancer-related pain and that the patient is already receiving opioids.

Program Background and Intent

The cDUR program is aligned with CDC opioid-treatment guidance and is designed to prevent misuse and dangerous combinations of opioids with other medications by screening prescriptions at point-of-service and via retrospective review. It identifies high-risk patterns such as multiple prescribers or pharmacies, overlapping opioid therapies, high daily MME, and opioid-related overdoses to prompt prescriber outreach or other interventions.

To support safe prescribing, the program enforces utilization management and prior authorization policies (for example, for long-acting and transmucosal fentanyl products) and point-of-sale edits that limit initial short-acting opioid fills and flag potentially hazardous co-prescriptions; these measures aim to reduce overdose risk and ensure appropriate monitoring and follow-up.

Clinical Thresholds and Definitions

inv-14: MME threshold referenced in program (90 MME cumulative limit)

Program MME threshold90 MME cumulative limit — used as the program threshold to prevent processing of cumulative opioid doses exceeding this limit.

Where appliedEnforced at point-of-sale and monitored via rDUR analyses to identify high daily doses.

Associated actionsTriggers prevention of claim processing and prescriber outreach through rDUR when exceeded.

New-to-Therapy Short-Acting Opioid Limits

New-to-therapy SAO limits

Point-of-sale limits for new therapy:

Opioid-naïve adults (no opioid claims in the last 60 days) are limited at point-of-sale to a maximum initial short-acting opioid (SAO) fill of a 5-day supply; prior authorization is required to exceed this initial supply.5 days

Applies to members age 18 and older.

Patients younger than 18 years: For members under 18, point-of-sale limits include a maximum 5-day supply for all SAO fills (initial and refills), a maximum of 180 units per 30 days, and a maximum of 2 unique SAO products within a 30-day period; prior authorization is required to exceed these quantities.5 days; 180 units/30 days; 2 unique products

Pediatric-specific limits and prior authorization pathway.

Step Requirements for Fentanyl Products

Requirement	Details
Step requirement
Step through two preferred short-acting (SAO) fentanyl patches is required unless there is documentation of a cancer diagnosis or palliative care–related pain.

Quantity Limits for Opioid-Containing Products

inv-17: Cough and cold products containing opioids — 120 mL per fill; 360 mL per 30 days

Per‑fill limit (cough/cold opioids)120 mL (units) per fill.

30‑day limit (cough/cold opioids)360 mL (units) per 30 days.

Prior authorization for minorsRequires prior authorization for members under 18 for cough and cold products containing opioid components.