CurrentGeorgia Department of Community HealthPolicy N/A

Georgia Medicaid Fee-for-Service — Long-acting Narcotics Prior Authorization

Customize your policy alerts

Sign up for all Georgia Department of Community Health policy alerts

Know when Georgia Department of Community Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Rules for prior authorization of long-acting narcotic analgesics for Georgia Medicaid Fee-for-Service members, including clinical criteria, required documentation, and length of authorization affecting prescribers and pharmacies.

Policy Summary

PayerGeorgia Department of Community Health

PolicyLong-acting narcotics prior authorization (Georgia Medicaid FFS)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with required documentation, including written letters of medical necessity for non-preferred products or non-standard strengths and documentation of prior failures or contraindications to preferred agents.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthslength of authorization

>50 MME/dayopioid‑naïve PA threshold

>120 MME/dayopioid‑experienced PA threshold

cancer/HIV/sickle cell

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentGeorgia Department of Community HealthPolicy N/A

Georgia Medicaid Fee-for-Service — Long-acting Narcotics Prior Authorization

Customize your policy alerts

Sign up for all Georgia Department of Community Health policy alerts

Know when Georgia Department of Community Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerGeorgia Department of Community Health

PolicyLong-acting narcotics prior authorization (Georgia Medicaid FFS)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthslength of authorization

>50 MME/dayopioid‑naïve PA threshold

>120 MME/dayopioid‑experienced PA threshold

cancer/HIV/sickle cell

diagnoses for approvability

Coverage Criteria for Long-Acting Opioids

Belbuca (buprenorphine buccal) criteria

Belbuca approvable when:

Belbuca_approvable_conditions: (1) Member has a diagnosis of cancer, HIV, or sickle cell anemia; OR (2) Member requires >80 mg/day oral morphine equivalence, is unable to swallow solid oral dosage forms, has moderate-to-severe chronic non-malignant pain requiring daily, around-the-clock, long-term opioid treatment, and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effect to the preferred fentanyl patch (12, 25, 50, 75, 100 mcg/hr); OR (3) Member requires >80 mg/day oral morphine equivalence, is able to swallow solid oral dosage forms, has moderate-to-severe chronic non-malignant pain requiring daily, around-the-clock, long-term opioid treatment, and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effect to the preferred products morphine sulfate ER tablets and fentanyl patch; OR (4) Member requires <80 mg/day oral morphine equivalence and prescriber submits a written letter of medical necessity stating why the preferred product Butrans is not appropriate for the member.>80 mg/day MME referenced

Prescriber must submit a written letter of medical necessity for members requiring <80 mg/day

Conzip and Tramadol ER generics

Conzip and tramadol ER generics approvable when:

Tramadol_nonpreferred: Prescriber submits a written letter of medical necessity stating the reasons the preferred product, generic tramadol ER (generic Ultram ER), is not appropriate for the member.

Letter of medical necessity required

Fentanyl patch non-standard strengths

Fentanyl patch non-standard strengths (37.5, 62.5, 87.5 mcg/hr) approvable when:

Fentanyl_nonstandard_strengths: Prescriber submits a written letter of medical necessity stating the reasons the preferred strengths (fentanyl patch 12, 25, 50, 75, 100 mcg/hr) are not appropriate for the member.

Strength-specific medical necessity letter required

Hydromorphone ER and morphine sulfate ER capsules

Hydromorphone ER and morphine sulfate ER capsules approvable when:

Hydromorphone_MorphCaps_approvable: (1) Member has a diagnosis of cancer, HIV, or sickle cell anemia; OR (2) Member has moderate-to-severe chronic nonmalignant pain requiring daily, around-the-clock, long-term opioid treatment and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effect to the preferred products morphine sulfate ER tablets and fentanyl patch.

Hysingla ER

Hysingla ER approvable when:

Hysingla_approvable: (1) Member has a diagnosis of cancer, HIV, or sickle cell anemia; OR (2) Member has moderate-to-severe chronic nonmalignant pain requiring daily, around-the-clock, long-term opioid treatment, has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to the preferred products morphine sulfate ER tablets and fentanyl patch, AND has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to the following non-preferred products: hydromorphone ER, morphine sulfate ER capsules, Nucynta ER, OxyContin, and oxymorphone ER.

Requires multiple prior product failures or contraindications

Levorphanol

Levorphanol approvable when:

Levorphanol_approvable: (1) Member has a diagnosis of cancer, HIV, or sickle cell anemia; OR (2) Member has severe chronic non-malignant pain (e.g., advanced illness, end of life) and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to the preferred products morphine sulfate ER tablets and fentanyl patch and to the non-preferred product methadone.

Targeted to severe or end-of-life situations

Nucynta ER (tapentadol ER)

Nucynta ER approvable when:

Nucynta_approvable: (1) Member has a diagnosis of cancer, HIV, or sickle cell anemia; OR (2) Member has moderate-to-severe chronic nonmalignant pain requiring daily, around-the-clock, long-term opioid treatment and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to the preferred products morphine sulfate ER tablets and fentanyl patch; OR (3) Member has neuropathic pain associated with diabetic peripheral neuropathy (DPN) requiring daily, around-the-clock, long-term opioid treatment and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to pregabalin (Lyrica), an antidepressant (amitriptyline, duloxetine, or venlafaxine), and morphine sulfate ER.

Includes DPN-specific pathway requiring failure of multiple non-opioid agents

OxyContin (oxycodone ER)

OxyContin approvable when:

OxyContin_approvable: (1) Member has a diagnosis of cancer, HIV, or sickle cell anemia; OR (2) Member has moderate-to-severe chronic nonmalignant pain requiring daily, around-the-clock, long-term opioid treatment and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to the preferred products morphine sulfate ER tablets and fentanyl patch. Requests for 60 mg, 80 mg, a single dose >40 mg, or a total daily dose >80 mg may be approvable for members with tolerance to high doses of opioids.

High-dose requests require documented tolerance

Oxymorphone ER

Oxymorphone ER approvable when:

Oxymorphone_approvable: (1) Member has a diagnosis of cancer, HIV, or sickle cell anemia; OR (2) Member has moderate-to-severe chronic nonmalignant pain requiring daily, around-the-clock, long-term opioid treatment and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to the preferred products morphine sulfate ER tablets and fentanyl patch, and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to the non-preferred product OxyContin.

Requires prior failure of OxyContin for non-cancer indications

Xtampza ER

Xtampza ER approvable when:

Xtampza_approvable: (1) Member has a diagnosis of cancer, HIV, or sickle cell anemia; OR (2) Member has moderate-to-severe chronic nonmalignant pain requiring daily, around-the-clock, long-term opioid treatment and has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to the preferred products morphine sulfate ER tablets and fentanyl patch. Requests for a single dose >36 mg (equivalent to 40 mg oxycodone) or total daily dose >72 mg (equivalent to 80 mg oxycodone) may be approvable for members with tolerance to high doses of opioids.

High-dose Xtampza requests require documented tolerance

Members receiving long-acting narcotics who are in long term care (LTC), hospice, or palliative care are excepted from certain MME limits. The policy notes that the usual opioid-experienced threshold that would trigger prior authorization denial (>120 MME/day) does not apply to members in LTC, hospice, or palliative care, and these settings should be documented to support approval under those exceptions.

The policy defines an opioid‑naïve prior authorization trigger: prescriptions for long‑acting narcotics for opioid‑naïve members will be rejected if they exceed 50 MME/day and are for a supply of more than 7 days, where the member has not previously been prescribed an immediate‑release opioid formulation. In addition, concurrent dispensing of buprenorphine or buprenorphine/naloxone products within the prior 7 days will result in a PA rejection. These limits are intended to prevent initiation of extended‑release/long‑acting therapy in patients without prior short‑acting opioid exposure and to avoid unsafe concurrent opioid agonist therapy.

Listed Long-Acting Opioid Products and Dose Limits

Listed long-acting opioid productsNDC | product

Butrans	transdermal buprenorphine (listed product)
Fentanyl patch generic	12, 25, 50, 75, 100 mcg/hour strengths
Morphine sulfate ER tablets
Tramadol ER generic	includes generic Ultram ER, Conzip, Ryzolt
Belbuca	buprenorphine buccal (non-preferred)
Conzip	tramadol ER
Fentanyl patch generic	37.5, 62.5, 87.5 mcg/hour strengths
Hydromorphone ER generic
Hysingla ER	hydrocodone ER
Levorphanol generic

1–10 of 15

1/2

Listed long-acting opioid products (alternate grouping)mixed

Butrans	transdermal buprenorphine (listed product)
Belbuca	buprenorphine buccal (non-preferred)
Fentanyl patch generic 12 mcg/hr
Fentanyl patch generic 25 mcg/hr
Fentanyl patch generic 37.5 mcg/hr
Fentanyl patch generic 50 mcg/hr
Fentanyl patch generic 62.5 mcg/hr
Fentanyl patch generic 75 mcg/hr
Fentanyl patch generic 87.5 mcg/hr
Fentanyl patch generic 100 mcg/hr

1–10 of 21

1/3

Dose limits for approvability / high tolerance

OxyContin high-dose single-dose thresholdSingle dose >40 mg (requests for 60 mg or 80 mg called out) may be approvable for members tolerant to high opioid doses

OxyContin total daily thresholdTotal daily dose >80 mg may be approvable for members tolerant to high opioid doses

Xtampza ER single-dose thresholdSingle dose >36 mg (equivalent to 40 mg oxycodone) may be approvable for members tolerant to high opioid doses

Xtampza ER total daily thresholdTotal daily dose >72 mg (equivalent to 80 mg oxycodone) may be approvable for members tolerant to high opioid doses

Prior Authorization, Documentation, and Step Therapy Requirements

Prior Authorization

Prior authorization required; 6-month approvals and exceptions

Prior authorization is required for the listed long-acting narcotics. The length of authorization is 6 months; exceptions may be requested through the prior authorization process with OptumRx.

Length of authorization: 6 months
Exceptions considered through the prior authorization process (contact OptumRx)

Step Therapy

Step therapy: document failure/intolerance to preferred agents

Approval for many non-preferred long-acting agents requires documentation that the member had an inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effect to specified preferred products (commonly morphine sulfate ER tablets and fentanyl patch).

Examples: failures to morphine sulfate ER tablets and fentanyl patch are required for hydromorphone ER, Hysingla ER, Nucynta ER, OxyContin, oxymorphone ER, and Xtampza ER pathways.

Failure or Intolerance to Alternatives

Background

Long‑acting opioid formulations are intended for daily, around‑the‑clock, long‑term opioid treatment for moderate‑to‑severe chronic pain, and for specific conditions such as cancer, HIV, or sickle cell anemia. The policy distinguishes between opioid‑naïve and opioid‑experienced thresholds to guide safe initiation and continuation of therapy, and it requires documentation (for non‑cancer diagnoses) of either a signed chronic opioid treatment plan or that the prescriber is a board‑certified pain management specialist. These measures support appropriate use and risk mitigation when prescribing extended‑release or long‑acting narcotics.

Definitions and Abbreviations

ER — Extended-release

DefinitionER = extended-release

Common useLong-acting formulations for daily, around-the-clock, long-term opioid treatment

Examples listed in policyMorphine sulfate ER tablets, hydromorphone ER, OxyContin, Xtampza ER, Nucynta ER, Hysingla ER

MME — Morphine milligram equivalents (thresholds)

Opioid‑naïve threshold>50 MME/day will hit a PA reject when prescribed >7‑day supply without prior immediate‑release opioid

Opioid‑experienced threshold>120 MME/day will hit a PA reject unless member has cancer or sickle cell anemia, or is in LTC/hospice/palliative care

Policy Summary

PayerGeorgia Department of Community Health

PolicyLong-acting narcotics prior authorization (Georgia Medicaid FFS)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Some agents require additional failures (e.g., Hysingla requires failures/intolerance to several non-preferred products).

Documentation Required

Letter of medical necessity required for concurrent buprenorphine therapy

When prescribing long-acting narcotics concurrently with buprenorphine or buprenorphine/naloxone opioid-dependency agents, the prescriber must submit a written letter of medical necessity explaining why concurrent therapy is necessary.

This written letter is required for any concurrent therapy with buprenorphine-containing opioid dependency agents.

Documentation Required

Written medical-necessity letter required for non-preferred products/strengths

For non-preferred products or non-standard strengths, the prescriber must submit a written letter of medical necessity stating why the preferred product or strength is not appropriate for the member.

Examples: written letters required for Belbuca when <80 mg/day and for Conzip/tramadol ER generics and for non-standard fentanyl patch strengths (37.5, 62.5, 87.5 mcg/hr).

Note

Chronic opioid treatment plan or board-certified prescriber required

For chronic non-cancer diagnoses, either the member must sign a chronic opioid treatment plan or the prescriber must be a board-certified pain management specialist.

This requirement applies unless the diagnosis is cancer, HIV, or sickle cell anemia.

Denial Risk

PA rejection triggers (including recent buprenorphine dispensing and MME thresholds)

Prior authorization will be rejected if the member has had buprenorphine or buprenorphine/naloxone dispensed within the past 7 days; other rejection triggers include opioid‑naïve members prescribed >50 MME/day with >7‑day supply without prior immediate‑release opioid, and opioid‑experienced members prescribed >120 MME/day unless cancer, sickle cell anemia, or in LTC/hospice/palliative care apply.

PA reject: concurrent buprenorphine or buprenorphine/naloxone dispensed within last 7 days.
PA reject: opioid‑naïve >50 MME/day with >7‑day supply without prior immediate‑release opioid.
PA reject: opioid‑experienced >120 MME/day unless cancer, sickle cell anemia, or LTC/hospice/palliative care.

PA concurrent-therapy trigger

PA reject if long-acting narcotic is prescribed while buprenorphine or buprenorphine/naloxone opioid-dependence agents were dispensed within the last 7 days