Opioid Agonist Prescribing and Prior Authorization
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Governs coverage and prior authorization for opioid agonist prescriptions for non-cancer, non-palliative, non-hospice, non-end-of-life pain for Community Health Plan Washington members; affects prescribers and pharmacies dispensing opioids.
No material clinical or coverage changes in this revision.
Coverage criteria for opioid prescribing
Initial and ongoing opioid prescribing criteria
Covered when ALL of the following are met
Exceptions exist for cancer, hospice, palliative, or end-of-life care and other specified exceptions.
Only short-acting opioids authorized for acute pain; long-acting opioids for acute use require exception criteria.
Authorization may be granted up to 12 months; attestation must be signed by a prescriber who has written an opioid for the patient within the previous 90 days.
Pharmacy must document source and date if criteria are provided telephonically.
Exceptions to MME limits
Authorization to exceed 120 MME/day (special circumstances)
Prescriber qualifications include listed WACs, completion of ≥12 continuing education hours on chronic pain (with ≥2 hours on substance use disorders), practice in a multidisciplinary chronic pain center/academic facility, ≥3 years clinical experience, or obtaining consultation with a pain management specialist.
This policy does not apply to opioid prescriptions written for patients receiving active cancer treatment, hospice care, palliative care, or end-of-life care when the prescriber indicates one of these conditions on the prescription. When the prescriber documents 'CANCER PAIN', 'HOSPICE', 'PALLIATIVE CARE', or 'END OF LIFE CARE' on the prescription, pharmacies may submit the claim with EA code 85000000540 to override the quantity and days-supply limits for short-acting opioids. Note that this exception does not override the 120 MME/day maximum unless other exception criteria are met and documented.
Opioid prescriptions that exceed the limits specified in this policy will be considered not medically necessary unless an applicable exception, required attestation, specialist consultation, or sufficient clinical documentation is provided. Routine coverage is limited to 120 MME per day; single or combined opioid claims that cumulatively exceed 120 MME/day but are ≤ 200 MME/day require consultation with a pain management specialist, and doses that exceed 200 MME/day will be reviewed on a case-by-case basis with chart notes and a pain specialist consultation required.
Covered products and definitions used for coding
| benzhydrocodone | ingredient listed |
| buprenorphine | ingredient listed (pain indications only) |
| butorphanol | ingredient listed |
| codeine | ingredient listed |
| dihydrocodeine | ingredient listed |
| fentanyl | ingredient listed |
| hydrocodone | ingredient listed |
| hydromorphone | ingredient listed |
| levorphanol | ingredient listed |
| meperidine | ingredient listed |
Provider requirements and prior authorization
Dose over MME limits — dosing thresholds and required documentation
Use of opioids is limited to 120 MME per day. All single or combined opioid claims that cumulatively exceed 120 MME per day but are no more than 200 MME per day require consultation with a pain management specialist and documentation of the exception. Claims that cumulatively exceed 200 MME per day will be reviewed on a case-by-case basis for medical necessity; chart notes including a consultation with a pain specialist for the requested dose are required. Authorization for doses above 120 MME/day may be allowed only under the documented exception criteria (see items).
- Maximum daily MME limit = 120 MME/day (standard).
- 120–200 MME/day: requires consultation with a pain management specialist and documented exception.
- >200 MME/day: case-by-case review; require chart notes and pain specialist consultation.
- Patients needing >120 MME/day may qualify if: ER/urgent-care opioid prescription ≤10 days (max 2 times/12 months); OR prescriber submits signed Opioid Attestation documenting one of: escalation for chronic therapy ≤200 MME/day for ≤42 days, tapering initiation >120 to ≤200 MME/day, or other medically necessary need; AND prescriber meets specialist or training requirements (see policy).
- Exceptions may include active cancer treatment, hospice, palliative or end-of-life care (provider must note 'CANCER PAIN', 'HOSPICE', 'PALLIATIVE CARE', or 'END OF LIFE CARE' on the prescription).
Chronic use prior authorization
Prior authorization is required for chronic opioid use defined as >42 days of opioid use within a rolling 90-day period. Reauthorization requires an updated, signed Opioid Attestation form; opioid attestation requests for chronic use will not be accepted until the patient has been on opioid therapy for at least 25 days in a 90-day period. Authorization may be granted up to 12 months or the time requested on the attestation, whichever is less.
- Chronic use = >42 days within a 90-day period.
- Attestation must be signed by a prescriber who has written an opioid prescription for the patient within the previous 90 days.
- Reauthorization: updated signed attestation required; may authorize up to 12 months.
Preferred agent trial requirements
Non-preferred agents require documented inadequate response or intolerance to at least two preferred agents from the Apple Health Preferred Drug List. If only one preferred agent exists in the class, documentation of inadequate response to that one agent is sufficient. New-to-market drugs included in this class per the AHPDL are non-preferred and subject to these PA criteria.
- Refer to the Apple Health Preferred Drug List: https://www.hca.wa.gov/assets/billers-and-providers/applehealth-preferred-drug-list.xlsx
- Document trials of TWO preferred agents (or ONE if only one preferred agent exists) showing inadequate response or intolerance.
Required clinical documentation
Providers must document baseline and ongoing objective pain and function scores, results of periodic urine drug screens, PDMP checks, discussion of goals and discontinuation, and that the patient has signed a pain contract or informed consent. For long-acting opioids, document prior short-acting opioid use for at least 42 days or clinical justification why short-acting opioids are inappropriate or ineffective. Authorization requests must include the required clinical documentation and, when applicable, chart notes supporting exceptions to MME limits.
- Baseline and ongoing measurable pain and function assessments.
- Periodic urine drug screening results.
- Prescription Drug Monitoring Program (PDMP) check documentation and review of concurrent benzodiazepine/sedative use.
- Discussion with patient of realistic goals and discontinuation options; signed pain contract/informed consent.
- For long-acting opioids: documentation of ≥42 days short-acting opioid use or clinical justification for starting long-acting therapy.
Non-opioid and conservative therapy requirements
Key definitions used in this policy
Clinical background and rationale
Opioid agonists are reserved for treatment of severe pain that cannot be managed with non-pharmacologic therapies or non-opioid medications. They exert their effect by acting on central and peripheral opioid receptors and are available in short-acting and long-acting formulations. This policy applies to products FDA-approved for acute or chronic pain that contain listed opioid ingredients and requires that, for chronic use, objective baseline and ongoing assessments (pain and function scores), periodic urine drug screening, PDMP checks, discussion of goals and discontinuation, and a signed pain contract or informed consent be documented in the medical record.
Exclusions and not-covered indications
Use of opioids for indications outside FDA-approved pain indications is not covered without a case-by-case review. Requests that fall outside approved pain indications must be supported by clinical justification and will be evaluated for medical necessity on an individual basis.
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