CurrentHealthy Blue LouisianaPolicy WEB-PEC-0680-17

Opioid Management Program Louisiana Medicaid

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This policy governs prior authorization, quantity limits, and approval criteria for opioid analgesics under Healthy Blue Louisiana Medicaid pharmacy benefits. It does not apply to Medicare or members without pharmacy benefits. Cancer-related, palliative-care, and end-of-life pain treatment is exempt from prior authorization.

Policy Summary

PayerHealthy Blue Louisiana

PolicyOpioid Management Program Louisiana Medicaid

Policy CodePolicy N/A

Change TypeMaterial revision

Effective DateSeptember 12, 2017

Next Review DateN/A

Key ActionSubmit the completed Louisiana Opioid Analgesic Treatment Worksheet for every opioid prior authorization and quantity-limit override.

SourceLink

POLICY UPDATE CHANGES

The morphine equivalent dose limit for opioid recipients was reduced from 120 mg per day to 90 mg per day effective September 12, 2017.

A seven-day quantity limit of 28 tablets or capsules within a 30-day period was implemented for short-acting opioids used for acute pain in opioid-naive recipients effective July 10, 2017.

The opioid management requirements were expanded from new opioid starts to all members using opioid analgesics effective May 22, 2017.

90 mg MED/dayMaximum morphine equivalent dose

28 tablets/capsulesShort-acting opioid limit

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CurrentHealthy Blue LouisianaPolicy WEB-PEC-0680-17

Opioid Management Program Louisiana Medicaid

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Policy Summary

PayerHealthy Blue Louisiana

PolicyOpioid Management Program Louisiana Medicaid

Policy CodePolicy N/A

Change TypeMaterial revision

Effective DateSeptember 12, 2017

Next Review DateN/A

Key ActionSubmit the completed Louisiana Opioid Analgesic Treatment Worksheet for every opioid prior authorization and quantity-limit override.

SourceLink

POLICY UPDATE CHANGES

The morphine equivalent dose limit for opioid recipients was reduced from 120 mg per day to 90 mg per day effective September 12, 2017.

A seven-day quantity limit of 28 tablets or capsules within a 30-day period was implemented for short-acting opioids used for acute pain in opioid-naive recipients effective July 10, 2017.

The opioid management requirements were expanded from new opioid starts to all members using opioid analgesics effective May 22, 2017.

90 mg MED/dayMaximum morphine equivalent dose

28 tablets/capsulesShort-acting opioid limit

Long-acting opioids requiring prior authorization

2 weeksPrior short-acting opioid trial

3Prior authorization exemptions

General and Long-Acting Opioid Coverage Criteria

General opioid approval criteria

Approval requires criterion I OR all criteria II through VIII.

Criterion I: The individual is using the opioid for treatment of pain related to cancer, palliative care, or end-of-life care.

This pathway does not require prior authorization.

Criteria II through VIII

All of the following: The prescriber has completed an assessment for pain and function, with documentation attached.
The individual has been screened for substance abuse or opioid dependence, with documentation attached.
The prescription monitoring program will be accessed each time a controlled prescription is written.
A treatment plan, including current and previous goals of therapy for both pain and function, has been developed.
The prescriber has explained the criteria for failure of the opioid trial and for stopping or continuing the opioid.
The benefits and potential harms of opioid use have been discussed with the individual. When comorbidities or interacting medications may increase risk, the prescriber has assessed and discussed the risk of respiratory depression, addressed the risks of combining opioids with central nervous system depressants such as benzodiazepines, alcohol, or illicit drugs such as heroin, and discussed the risk of opioid abuse or overdose at the prescribed dose and duration.
An Opioid Treatment Agreement signed by both the patient and prescriber is on file.
Not required for individuals in a long-term care facility.

Long-acting opioid criteria

For long-acting opioids, all additional criteria I through V must also be met.

All additional long-acting opioid criteria

The individual requires continuous, around-the-clock analgesic therapy for which alternative treatment options have been inadequate or have not been tolerated.
The individual previously used a short-acting opioid for this condition for at least two weeks.At least 2 weeks
Enter the drug, dose, duration, and date of the trial in the Pharmacological Treatment section on page 1 of the Opioid Treatment Worksheet.
The medication has not been prescribed to treat acute pain, mild pain, or pain that is not expected to persist for an extended period of time.
The medication has not been prescribed for use as an as-needed (PRN) analgesic.

Long-acting opioids are not approved for acute pain, mild pain, or pain that is not expected to persist for an extended period. They are also not approved when prescribed for as-needed (PRN) analgesia.

Initial Opioid Therapy

Initial opioid therapy

For initial opioid approval, criterion I may qualify the request, or criteria II through VIII must all be met.

Criterion I: The individual is using the opioid for treatment of pain related to cancer, palliative care, or end-of-life care.

No prior authorization is required for this pathway.

Criteria II through VIII

The prescriber has completed an assessment for pain and function, with documentation attached.
The individual has been screened for substance abuse or opioid dependence, with documentation attached.
The prescription monitoring program will be accessed each time a controlled prescription is written.

Required Prior Short-Acting Opioid Trial

Step	Requirement	Required documentation
1	Before approval of a long-acting opioid, the individual must have used a short-acting opioid for the condition for at least two weeks.	Document the short-acting opioid drug, dose, duration, and trial date in the Pharmacological Treatment section of the Opioid Treatment Worksheet.

Dose and Acute-Pain Quantity Controls

Morphine Equivalent Dose

Daily limit90 mg MED per day

Applies toOpioid-naive and opioid-tolerant individuals

Effective dateSeptember 12, 2017

Short-Acting Opioid Acute-Pain Quantity Limit

Quantity limit28 tablets or capsules

Supply duration7-day supply

Time periodWithin a 30-day period

State-Defined Opioid Quantity Limits

Quantity Limits

ScopeAll opioids

State authorityQuantity limits established by the State of Louisiana under HPA16-35

Quantity-limit overrideRequests exceeding the limit must use the Louisiana Opioid Analgesic Treatment Worksheet

All Opioid Agents

Maximum dose90 mg morphine equivalent dose per day

Applies toAll opioid agents

Member populationsOpioid-naive and opioid-tolerant individuals

Authorization, Documentation, and Exceptions

Prior Authorization

Prior Authorization Required for Long-Acting Opioids

Prior authorization is required for all long-acting opioid analgesics. Requests must use the Louisiana Opioid Analgesic Treatment Worksheet; quantity-limit overrides for long-acting opioids also require the worksheet.

All opioids are subject to state quantity limits under HPA16-35.
All opioid prior authorization requests must use the common Louisiana worksheet.

Note

Cancer and Palliative-Care Exception

Prior authorization is not required when the opioid is used to treat pain related to cancer, palliative care, or end-of-life care.

Cancer-related pain
Palliative care
End-of-life care

Opioid Management Program

Healthy Blue Louisiana Medicaid manages opioid exposure through prior authorization, state-defined quantity limits, and morphine equivalent dose (MED) controls. The MED limit is 90 mg per day for opioid-naive and opioid-tolerant individuals; listed short-acting opioids for acute pain in opioid-naive recipients are limited to 28 tablets or capsules for a 7-day supply within a 30-day period.

These requirements apply to the Louisiana Medicaid pharmacy benefit and do not apply to Medicare, members without pharmacy benefits, or specified transition-of-care limitations. Prior authorization is not required for opioid treatment of cancer-related pain, palliative care, or end-of-life care.

Key Opioid Management Terms

Definition

TermOpioid-naive

DefinitionAn individual with no opioid therapy in the previous 90 days

Related limitShort-acting opioids for acute pain are limited to 28 tablets or capsules for a 7-day supply within a 30-day period

Definition

TermMED

MeaningMorphine equivalent dose

DefinitionThe equivalent daily morphine dose used to express the opioid dose

Policy Summary

PayerHealthy Blue Louisiana

PolicyOpioid Management Program Louisiana Medicaid

Policy CodePolicy N/A

Change TypeMaterial revision

Effective DateSeptember 12, 2017

Next Review DateN/A

Key ActionSubmit the completed Louisiana Opioid Analgesic Treatment Worksheet for every opioid prior authorization and quantity-limit override.

SourceLink

On This Page

The prescriber has thoroughly reviewed the prescribing information for the requested product.

A treatment plan, including current and previous goals of therapy for both pain and function, has been developed.

The prescriber has explained the criteria for failure of the opioid trial and for stopping or continuing the opioid.

The benefits and potential harms of opioid use have been discussed with the individual. When comorbidities or interacting medications may increase risk, the prescriber has assessed and discussed the risk of respiratory depression, addressed the risks of combining opioids with central nervous system depressants such as benzodiazepines, alcohol, or illicit drugs such as heroin, and discussed the risk of opioid abuse or overdose at the prescribed dose and duration.

An Opioid Treatment Agreement signed by both the patient and prescriber is on file.

Not required for individuals in a long-term care facility.

Short-Acting Opioids for Acute Pain

Affected medicationsListed short-acting opioids for acute pain

PopulationOpioid-naive individuals

Limit28 tablets or capsules for a 7-day supply within a 30-day period

Step Therapy

Short-Acting Opioid Trial Required

Before long-acting opioid therapy is approved, the individual must have used a short-acting opioid for this condition for at least two weeks. The worksheet must identify the drug or drugs, dose, duration, and trial date.

Document the prior short-acting opioid trial in the Pharmacological Treatment section on page 1 of the worksheet.
Short-acting opioids remain subject to state quantity limits.

Documentation Required

Louisiana Opioid Worksheet and Supporting Records

Submit the completed Louisiana Opioid Analgesic Treatment Worksheet with every opioid prior authorization request and with requests to override state quantity limits. Requests submitted without the worksheet will not be processed or approved.

Long-acting opioid prior authorization requests require the worksheet.
Long-acting opioid quantity-limit overrides require the worksheet.
Short-acting opioid quantity-limit overrides require the worksheet.
Attach supporting clinical records and enter the requested short-acting trial drug(s), dose, duration, and date when applicable.

Documentation Required

Monitoring and Risk Documentation

For each controlled prescription, the prescriber must access the prescription monitoring program and document the required opioid risk assessment and discussion.

Assess and document pain and function.
Screen for substance abuse and opioid dependence; attach the documentation.
Develop current and previous treatment goals for pain and function.
Explain the criteria for opioid-trial failure and for stopping or continuing therapy.
Discuss benefits and potential harms, including respiratory-depression risk from comorbidities or drug interactions.
Address risks of combining opioids with benzodiazepines, alcohol, heroin, or other central nervous system depressants.
Discuss the patient’s opioid-abuse and overdose risk based on the prescribed dose and duration.

Documentation Required

Opioid Treatment Agreement

A signed Opioid Treatment Agreement must be on file for both the patient and prescriber before approval. The agreement is not required for individuals in a long-term care facility.

Retain signatures from both the patient and prescriber.
Long-term-care-facility residents are excepted from this requirement.

Prior Authorization

Worksheet Required for Processing

The Louisiana Opioid Analgesic Treatment Worksheet is mandatory for opioid prior authorization requests. Requests submitted without the completed worksheet will not be approved.

Complete the worksheet for all applicable opioid prior authorization requests.
Use the worksheet for quantity-limit override requests.

Denial Risk

Missing Clinical Documentation May Result in Denial

Missing required clinical documentation creates a denial risk. The record must support the pain and function assessment, substance-abuse or opioid-dependence screening, treatment planning, opioid counseling, and related risk evaluations.

Attach the pain and function assessment.
Attach substance-abuse and opioid-dependence screening documentation.
Document current and previous pain and function goals.
Document counseling on opioid benefits, harms, treatment failure, discontinuation, and continuation.
Document respiratory-depression and drug-interaction risk when applicable.

Denial Risk

Long-Acting Opioid Criteria Not Met

Long-acting opioid therapy may be denied when continuous around-the-clock analgesia is not required or when alternative treatment options are adequate or tolerated. Approval also requires that the medication is not being used for acute, mild, short-duration, or as-needed pain and that the prescribing information has been reviewed.

The individual must require continuous around-the-clock analgesia.
Alternative treatment options must have been inadequate or not tolerated.
Do not prescribe the requested long-acting opioid for acute pain, mild pain, or pain not expected to persist for an extended period.
Do not prescribe it as a PRN analgesic.
The prescriber must thoroughly review the requested product’s prescribing information.
If any required attestation is answered NO, provide a written rationale.