CurrentFidelis CarePolicy N/A

Opioid Prior Authorization Requirements

Defines Fidelis Care prior authorization requirements for opioid prescriptions (immediate- and extended-release) including quantity limits, daily MME thresholds, trials of immediate-release opioids, documentation and expedited request instructions for members in the payer's coverage (NY state focused). Affects prescribers and pharmacy staff submitting PAs.

Policy Summary

PayerFidelis Care

PolicyOpioid Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed, signed PA form with clinical chart notes and required documentation via fax to 1-844-235-4852.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MME/dayCumulative daily dose threshold requiring prior authorization

7 daysMaximum immediate-release supply without prior opioid use

Initial trial requiredExtended-release initial trial (Commercial)

Fax: 1-844-235-4852PA form fax

Phone: 1-888-343-3547Contact phone

When Prior Authorization Is Required

Authorization triggers

Prior authorization required when ANY of the following conditions are met:

PA triggers: 1) Immediate‑Release or Extended‑Release opioid exceeding the quantity limit; 2) Any opioid exceeding a cumulative daily dose of 90 MME; 3) New start of an extended‑release opioid without an initial trial of at least a day supply of an immediate‑release opioid (Commercial lines of business only); 4) New immediate‑release opioid prescription exceeding a 7‑day supply without prior history of opioid use.

The PA form explicitly asks whether the opioid is being prescribed for pain related to cancer, a terminal condition, sickle cell disease, or for a member in hospice/palliative care. These indications are solicited on the form but are not listed as automatic exclusions from prior authorization — providers must still complete the PA and attach supporting chart notes when applicable. If one of these diagnoses applies, include documentation of the diagnosis and relevant clinical notes with the submission to support the request.

Dose Thresholds and MME

Daily MME threshold

Policy Summary

PayerFidelis Care

PolicyOpioid Prior Authorization Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed, signed PA form with clinical chart notes and required documentation via fax to 1-844-235-4852.

SourceLink

On This Page

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.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for opioid prescriptions that exceed quantity limits, result in a cumulative daily dose >90 MME, or are new starts of extended‑release opioids without required step therapy. To submit a request, fax the Fidelis Care Opioid Prior Authorization Form to 1-844-235-4852 or call 1-888-343-3547 for questions.

Requests exceeding quantity limits
Requests resulting in >90 MME/day cumulative dose
New extended‑release opioid starts without required trial (see step therapy)
New immediate‑release opioid prescriptions >7 day supply without prior opioid use documentation

Step Therapy

Step Therapy for Extended‑Release Opioids

For new starts of extended‑release (ER) opioid analgesics in Commercial lines of business, prescribers must first trial an adequate course of an immediate‑release (IR) opioid analgesic. The IR trial should be documented in the chart notes and included with the PA submission.

Applies to Commercial members only
Documented trial of at least a [number] day supply of an immediate‑release opioid prior to ER initiation
If trial not documented, PA may be denied

Documentation Required

Required Documentation

Include supporting clinical documentation with every PA request: diagnosis (ICD‑10), relevant medical history, prior non‑opioid and nonpharmacologic therapy trials, details of opioid use history when requesting >7‑day supply, urine drug screen results if available, and rationale for doses >90 MME/day.

Attach clinical chart notes documenting diagnosis and prior therapy trials
If requesting >7‑day supply for a new IR opioid, document prior opioid use history
If requesting >90 MME/day, include clinical rationale and supporting notes
Provide urine drug screen results when available
Confirm whether benzodiazepines will be excluded from the treatment plan

Denial Risk

Triggers for Denial

Requests will be denied when they exceed quantity limits or result in a cumulative daily dose >90 MME, when a new ER opioid is initiated without the required IR trial (Commercial only), or when required documentation is missing (e.g., chart notes, prior trial history, or urine drug screen results when requested).

Exceeding plan quantity limits
Cumulative daily dose >90 MME without documented rationale
New ER opioid start without documented IR trial (Commercial)
Requests for new IR opioid >7‑day supply without documented prior opioid use
Incomplete or missing clinical chart notes or required attachments

OpenPayer

Opioid Prior Authorization Requirements

When Prior Authorization Is Required

Dose Thresholds and MME

What Providers Must Do

Prior Trials and Non-Opioid Therapy Documentation

Clinical and Guideline Context

Terminology and Equivalences