OPIOID MEDICATIONS MME LIMITS, ICD-10 REQUIREMENT, AND PRIOR AUTHORIZATION CRITERIA
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Med-QUEST (Hawaii DHS) policy governing opioid prescribing limits (MME), ICD-10 coding on opioid prescriptions, prior authorization requirements, concurrent opioid-benzodiazepine limits, and informed consent for Fee-For-Service (FFS) Medicaid providers in Hawaii.
No material clinical or coverage changes in this revision.
Coverage and Authorization Criteria
Chronic non-cancer pain — PA criteria for >120 MME/day
Covered (PA required) when ALL of the following are met
Initial authorization for chronic non-cancer pain limited to 3 months; subsequent requests require justification and a plan of care.
Cancer-related pain — PA criteria and oncologist exception
Covered (PA required for non-oncologists) when ALL of the following are met
Authorization period for cancer-related pain is up to 6 months.
Concurrent opioid and benzodiazepine prescribing
Covered or authorized when ALL of the following are met
Subsequent prescriptions may be authorized by telephone when medically necessary, but an in-person consultation is required at least once every 90 days unless justification is provided.
The Dental program is managed separately: Dental program opioids are governed by a separate formulary and criteria for acute pain treatment, and therefore the limits and prior authorization rules in this memo do not apply to dental-only benefit claims. For oncology care, enrolled Medicaid oncologists have a distinct exception: when treating pain directly related to cancer, an enrolled Medicaid oncologist does not require prior authorization for daily opioid dosages exceeding 120 MME provided they supply the ICD-10 diagnosis to the pharmacy.
For chronic non-cancer pain, daily opioid dosing greater than 120 MME per day is not allowed under standard coverage without prior authorization. Authorization requests must be submitted by an enrolled Medicaid provider and include the ICD-10 diagnosis, the drug strength and total daily dosage, and documentation supporting the higher dose such as referral to a pain specialist (with name and plan of care), a plan of care for documented opioid dependence, or evidence the patient is in hospice, palliative, end-of-life, long-term care, or has another terminal diagnosis. No early refills will be allowed as part of the standard approval conditions.
Required Coding and Pharmacy Identifiers
| ICD-10 | International Classification of Diseases, Tenth Revision — prescribers shall include an ICD-10 diagnosis code on all opioid prescriptions; pharmacies must submit the ICD-10 on POS claims and include it on authorization forms. |
| NDC | Pharmacy must provide NDC numbers of the opioid strength(s) requested by the prescriber on the authorization form. |
Provider Responsibilities and Authorization Steps
PA required for >120 MME/day (chronic non‑cancer pain)
Prior authorization is required for daily opioid dosages exceeding 120 MME for chronic, non-cancer pain. Authorization requests must include the diagnosis and ICD-10, strength and total daily dosage, and no early refills will be allowed. Initial authorizations are limited to 3 months and requests must include justification (see step‑up requirements).
- Provide diagnosis and ICD-10 code.
- Provide opioid strength and total daily MME.
- No early refills allowed.
- Include justification for >120 MME (see step‑up justification block).
- Initial authorization limited to 3 months.
PA exception for enrolled Medicaid oncologists (cancer‑related pain)
Prior authorization is required for cancer‑related pain daily doses exceeding 120 MME when prescribed by non‑oncologists. Enrolled Medicaid oncologists are exempt from PA for >120 MME if the pain is directly related to cancer and the oncologist provides the ICD‑10 diagnosis to the pharmacy.
- Provide diagnosis and ICD‑10 code and strength/total daily dosage on the authorization.
- Prior authorization still required for early refills for dose adjustments or lost/stolen medications.
- No PA required for enrolled Medicaid oncologists when pain is directly cancer‑related and ICD‑10 is supplied to the pharmacy.
PA for >7‑day concurrent opioid + benzodiazepine supply
Authorization is required for more than an initial 7‑day concurrent supply of opioids and benzodiazepines. Requests must include diagnosis and ICD‑10 and strength and total daily dosages for both drugs, and document alternatives tried.
- Provide diagnosis and ICD‑10 code.
- Provide strength and total daily dosage for both the opioid and benzodiazepine.
- Document alternatives that were not appropriate for the diagnosis.
- No early refills will be allowed.
- Exceptions listed (e.g., hospice, cancer, palliative care, opioid dependence, Our Care, Our Choice Act).
Documentation for telephone‑authorized subsequent prescriptions
For subsequent opioid or benzodiazepine prescriptions authorized via telephone instead of an in‑person consult, include diagnosis and ICD‑10, strengths and total daily dosages for both drugs, reason for any dose adjustment, and justification for not performing the required in‑person consultation at least every 90 days.
- Provide diagnosis and ICD‑10 code.
- Provide strength and total daily dosage for both opioid and benzodiazepine.
- State reason for any dose adjustment.
- Include justification for why in‑person consultation every 90 days was not performed.
Step‑up justification required for >120 MME/day
Justification to exceed 120 MME/day must include evidence of referral to a pain specialist with the specialist’s name and plan of care attached if applicable, or documentation that the patient is physically opioid dependent or is in an eligible care setting (hospice, end‑of‑life, palliative, long‑term resident, or other terminal diagnosis).
- Attach name of pain specialist and plan of care when referred or being seen by one.
- If patient is opioid dependent, attach a plan of care for treatment.
- Document eligible care setting (hospice, end‑of‑life, palliative, long‑term resident, other terminal diagnosis) or prescriber enrollment in palliative/geriatric/hospice care.
Required documentation for PA requests and pharmacy claims
Authorization requests and pharmacy claims must include diagnosis and ICD‑10, strength and total daily dosage; pharmacies must provide NDC numbers of the opioid strengths requested and include the prescriber’s ICD‑10 on all opioid claims.
- Authorization forms: include diagnosis and ICD‑10, opioid strength and total daily MME.
- Pharmacies: provide NDC numbers for requested opioid strengths on the authorization form.
- Pharmacies must include the prescriber‑provided ICD‑10 diagnosis code on all opioid claims.
- For concurrent opioid/benzo >7 days or telephone‑authorized subsequent prescriptions, provide justification and documentation of alternatives considered and reasons.
Denial risk: missing documentation for >120 MME/day PA
Requests for daily opioid dosing over 120 MME require prior authorization; failure to provide the required diagnosis/ICD‑10, strength/total daily dosage, justification and supporting documentation (e.g., pain specialist name/plan of care, plan for opioid dependence, facility type) may result in denial.
- Omit required items and the request may be denied: diagnosis/ICD‑10, strength and total daily MME, justification and supporting attachments.
- No early refills allowed — missing this acknowledgement may contribute to denial.
Denial risk: cancer‑related >120 MME when not managed by Medicaid oncologist
Non‑oncologist prescribers must obtain prior authorization for cancer‑related pain daily doses >120 MME; failure to provide diagnosis/ICD‑10, strength/total daily dosage, or to follow PA rules for early refills may lead to denial. Enrolled Medicaid oncologists who supply the ICD‑10 to the pharmacy are exempt from PA for >120 MME when pain is directly cancer‑related.
- Provide diagnosis and ICD‑10 and strength/total daily dose on the authorization.
- Prior authorization required for early refills (dose adjustments, lost/stolen meds).
- If prescriber is an enrolled Medicaid oncologist and pain is cancer‑related, supply the ICD‑10 to the pharmacy to avoid PA.
Policy Background and Rationale
This policy is aligned with CDC guidance to reduce harms from high-dose opioid prescribing and to support safe chronic pain management. Key operational requirements include that prescribers must include an ICD-10 diagnosis code on all opioid prescriptions and pharmacies must submit the ICD-10 on point-of-sale claims. When daily opioid doses exceed 120 MME, prior authorization and informed justification are required (see chronic non-cancer and cancer-related criteria); for cancer-related pain, enrolled Medicaid oncologists may be exempt from PA when the pain is directly related to cancer and the oncologist provides the ICD-10 to the pharmacy.
Key Terms
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