CurrentHealthy Blue LouisianaPolicy N/A

Opioid Management Program Louisiana Medicaid

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This policy governs prior authorization, quantity limits, step therapy, and clinical documentation for opioid analgesics covered under Healthy Blue Louisiana Medicaid pharmacy benefits. It applies to opioid-naive and opioid-tolerant members, with specific requirements for long-acting and short-acting opioids.

Policy Summary

PayerHealthy Blue Louisiana

PolicyOpioid Management Program Louisiana Medicaid

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit all opioid prior authorization requests and quantity-limit overrides using the Louisiana Opioid Analgesic Treatment Worksheet.

SourceLink

POLICY UPDATE CHANGES

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

A seven-day quantity limit was implemented for short-acting opioids in opioid-naive recipients effective July 10, 2017.

Prior authorization requests and quantity-limit overrides for opioids must use the Louisiana Opioid Analgesic Treatment Worksheet.

The program was expanded from new opioid starts to all members utilizing opioid analgesics effective May 22, 2017.

90 mg MED/dayMaximum morphine-equivalent dose

7 daysShort-acting opioid supply limit for opioid-naive recipients

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CurrentHealthy Blue LouisianaPolicy N/A

Opioid Management Program Louisiana Medicaid

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Sign up for all healthybluelouisiana policy alerts

Know when healthybluelouisiana releases new policies or updates existing guidance.

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Policy Summary

PayerHealthy Blue Louisiana

PolicyOpioid Management Program Louisiana Medicaid

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit all opioid prior authorization requests and quantity-limit overrides using the Louisiana Opioid Analgesic Treatment Worksheet.

SourceLink

POLICY UPDATE CHANGES

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

A seven-day quantity limit was implemented for short-acting opioids in opioid-naive recipients effective July 10, 2017.

Prior authorization requests and quantity-limit overrides for opioids must use the Louisiana Opioid Analgesic Treatment Worksheet.

The program was expanded from new opioid starts to all members utilizing opioid analgesics effective May 22, 2017.

90 mg MED/dayMaximum morphine-equivalent dose

7 daysShort-acting opioid supply limit for opioid-naive recipients

Short-acting opioid units allowed per seven-day supply

2 agentsPreferred long-acting agents before a nonpreferred agent

2 weeksMinimum prior short-acting opioid use

90 daysOpioid-free period defining opioid-naive status

General and Long-Acting Opioid Coverage

General opioid approval criteria

Coverage requires criterion I OR all criteria II through VIII.

General opioid approval

Criterion I: The individual is using the opioid for pain related to cancer, palliative care, or end-of-life care.
Criteria II through VIII
- Criterion II: The prescriber has completed an assessment for pain and function, and documentation is attached.
- Criterion III: The prescriber has screened the individual for substance abuse or opioid dependence, and documentation is attached.
- Criterion IV: The prescription monitoring program will be accessed each time a controlled prescription is written.
- Criterion V: A treatment plan, including current and previous goals of therapy for both pain and function, has been developed.
- Criterion VI: The prescriber has explained the criteria for failure of the opioid trial and for stopping or continuing the opioid.
- Criterion VII: The benefits and potential harms of opioid use have been discussed with the individual. If the individual has concurrent comorbidities or takes medications that could cause drug-drug interactions, increased risk for respiratory depression has been assessed and discussed. The risks of combining opioids with benzodiazepines, alcohol, or illicit drugs such as heroin, and the risk of opioid abuse or overdose related to the prescribed dose and duration, have also been discussed.
- Criterion VIII: An Opioid Treatment Agreement signed by both the patient and prescriber is on file.
  Not required for individuals in a long-term care facility.

title":"General opioid approval criteria"},{

Long-acting opioid therapy

Coverage requires all general opioid approval criteria plus all additional long-acting opioid criteria.

Long-acting opioid coverage

General opioid approval criteria
- Cancer, palliative-care, or end-of-life pain: The individual is using the opioid for pain related to cancer, palliative care, or end-of-life care.
- General monitoring and documentation criteria
  - The prescriber has completed an assessment for pain and function, and documentation is attached.
  - The prescriber has screened the individual for substance abuse or opioid dependence, and documentation is attached.

Nonpreferred long-acting opioid criteria

A nonpreferred long-acting opioid may be approved when any one of criteria I through VI is met.

Nonpreferred long-acting opioid exceptions

Criterion I: The individual has had a trial with inadequate response or intolerance to two preferred long-acting agents: morphine sulfate extended release (generic MS Contin) and fentanyl patch.Two preferred agents
Criterion II: The individual has completed titration and is already maintained on a stable dose of the requested drug.
Criterion III: The preferred long-acting opioids are not acceptable because of a concomitant clinical situation.
Examples are not exhaustively listed in the policy.

This policy does not apply to health plans or member categories without pharmacy benefits and does not apply to Medicare. Market-specific restrictions or transition-of-care benefit limitations may still apply.

Long-acting opioid therapy is not appropriate for acute pain, mild pain, or pain not expected to persist for an extended period. It is also not appropriate when prescribed as an as-needed (PRN) analgesic.

Dose, Supply, and Treatment Thresholds

Maximum morphine-equivalent dose

Maximum dose90 mg morphine equivalent dose (MED) per day

Applies toOpioid-naive and opioid-tolerant individuals

Effective dateSeptember 12, 2017

Short-acting opioid quantity limit

Quantity limit28 tablets or capsules

Supply durationSeven-day supply

Time periodWithin a 30-day period

Authorization, Documentation, and Denial Rules

Prior Authorization

Prior Authorization Required for Long-Acting Opioids

All long-acting opioid analgesics require prior authorization before dispensing.

Documentation Required

Louisiana Opioid Worksheet Required

Every opioid prior authorization request must be submitted using the Louisiana Opioid Analgesic Treatment Worksheet provided by the State of Louisiana.

This requirement applies to requests for any opioid, including long-acting and listed short-acting opioids.

Prior Authorization

Quantity-Limit Override Authorization

Quantity-limit overrides for long-acting opioids and the listed short-acting opioids must be requested using the Louisiana Opioid Analgesic Treatment Worksheet.

Opioid Management Program

The Opioid Management Program manages opioid analgesic use through prior authorization, state-established quantity limits, morphine-equivalent-dose (MED) limits, step therapy, and clinical documentation requirements. All opioid analgesics are subject to a 90 mg MED/day limit, with additional quantity limits for specified products and short-acting opioids for opioid-naive individuals. Long-acting therapy generally requires prior short-acting opioid use for at least two weeks, and nonpreferred long-acting products generally require inadequate response or intolerance to two preferred agents.

Key Policy Definitions

Opioid-naive

DefinitionAn individual with no opioid therapy during the previous 90 days

Relevant quantity limitShort-acting opioids are limited to 28 tablets or capsules per seven-day supply within a 30-day period

MED applicabilityThe 90 mg MED-per-day limit applies to opioid-naive and opioid-tolerant individuals

MED

MeaningMorphine equivalent dose

Policy limitAll opioid agents are limited to 90 mg MED per day

Applies to

Initial Opioid Therapy

Initial opioid therapy

Initial opioid therapy requires the general opioid approval criteria.

Initial opioid approval

The individual is using the opioid for pain related to cancer, palliative care, or end-of-life care.
All required monitoring and documentation criteria
- The prescriber has completed an assessment for pain and function, and documentation is attached.
- The prescriber has screened the individual for substance abuse or opioid dependence, and documentation is attached.
- The prescription monitoring program will be accessed each time a controlled prescription is written.

Stable Maintenance Therapy

Stable maintenance

Continuation of a requested nonpreferred long-acting opioid may be approved when the individual has completed titration and is maintained on a stable dose.

Stable maintenance continuation

The individual has completed titration and is already maintained on a stable dose of the requested drug.

Required Prior Therapy

Step	Preferred therapy requirement	Applies before
1	Try both preferred long-acting agents: morphine sulfate extended release (generic MS Contin) and fentanyl patch. The trial must result in an inadequate response or intolerance.	A nonpreferred long-acting opioid

Step	Prior therapy requirement	Applies before
1	Use short-acting opioids for the condition for at least two weeks before initiating long-acting opioid therapy. Alternative treatment options must have been inadequate or not tolerated.	A long-acting opioid

State and Policy Quantity Limits

All opioid analgesics

Drug scopeAll opioid analgesics

Limit90 mg morphine equivalent dose

PerDay

Short-acting opioids for opioid-naive recipients

Drug scopeShort-acting opioids for opioid-naive recipients

Quantity limit28 tablets or capsules

Supply durationWithin a seven-day supply

Policy Summary

PayerHealthy Blue Louisiana

PolicyOpioid Management Program Louisiana Medicaid

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit all opioid prior authorization requests and quantity-limit overrides using the Louisiana Opioid Analgesic Treatment Worksheet.

SourceLink

On This Page

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, respiratory-depression risk, risks from concurrent comorbidities or interacting medications, risks of combining opioids with benzodiazepines, alcohol, or illicit drugs, and opioid abuse or overdose risk related to dose and duration have been discussed.

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

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

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 short-acting opioids for this condition for at least two weeks.At least two weeks
Enter the drug, dose, duration, and date of the trial in the Pharmacological Treatment section of page 1 of the Louisiana Opioid Analgesic 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 analgesic.
The prescriber has thoroughly reviewed the prescribing information for the requested product.

title":"Long-acting opioid therapy"},{

Criterion IV: The individual has known hypersensitivity to an ingredient that is not also present in the requested nonpreferred agent.

Criterion V: An abuse-deterrent agent may be approved when the individual needs an abuse-deterrent formulation because of a history of substance abuse disorder, or because a family member or household resident has active substance abuse disorder or a history of substance abuse disorder.

Abuse-deterrent agents listed in the policy include OxyContin, Hysingla ER, Targiniq ER, Embeda, MorphaBond, Xtampza ER, Troxyca ER, Vantrela ER, and Arymo ER.

Criterion VI: The requested nonpreferred agent is Butrans (buprenorphine transdermal patch) or Belbuca (buprenorphine buccal film), and there is concern for abuse or dependence with pure opioid agents.

title":"Nonpreferred long-acting opioid criteria"},{

Prior short-acting opioid trial

Minimum prior useAt least two weeks of short-acting opioids for the condition

Required documentationEnter the drug, dose, duration, and trial date in the Pharmacological Treatment section of the Louisiana Opioid Analgesic Treatment Worksheet

Applies beforeInitiation of long-acting opioid therapy

Opioid-naive definition

DefinitionAn individual with no opioid therapy during the previous 90 days

Initial program scopeApplied to new opioid starts on March 22, 2017

Quantity-limit scopeShort-acting opioid seven-day quantity limit applies to opioid-naive recipients

State quantity limits apply under HPA16-35 and HPA17-7.
The worksheet is required for each quantity-limit override request.

Step Therapy

Preferred Long-Acting Opioid Trial

A nonpreferred long-acting opioid generally requires a trial with inadequate response or intolerance to two preferred long-acting agents.

Preferred agents are morphine sulfate ER (generic MS Contin) and fentanyl patch.
Exceptions may include stable maintenance on the requested drug, unacceptable preferred therapy because of clinical circumstances or hypersensitivity, need for an abuse-deterrent formulation, or concern about abuse or dependence with pure opioid agents for Butrans or Belbuca.

Step Therapy

Cancer and Palliative-Care Exception

Pain related to cancer, palliative care, or end-of-life treatment does not require prior authorization, but remains subject to step therapy.

Documentation Required

Pain, Function, and Substance-Use Assessment

Attach a documented assessment of pain and function and documentation that the individual was screened for substance abuse or opioid dependence. The prescription monitoring program must be accessed each time a controlled prescription is written.

Complete the Louisiana Opioid Analgesic Treatment Worksheet.

Documentation Required

Treatment Plan and Monitoring Goals

Document a treatment plan with current and previous goals for both pain and function, and explain the criteria for opioid-trial failure and for stopping or continuing treatment.

The prescriber must provide a written rationale if unable to attest to a required criterion.

Documentation Required

Opioid Risk Counseling

Document counseling on the benefits and potential harms of opioid use, including abuse, overdose, and respiratory-depression risk.

Address increased risk from comorbidities and drug interactions.
Specifically discuss combining opioids with benzodiazepines, alcohol, heroin, or other central nervous system depressants.
Discuss the abuse and overdose risk associated with the prescribed dose and duration.

Documentation Required

Opioid Treatment Agreement

Maintain an opioid treatment agreement signed by both the patient and prescriber.

The agreement is not required for individuals in a long-term care facility.

Documentation Required

Prior Short-Acting Opioid Trial

For long-acting opioid requests, document at least two weeks of prior short-acting opioid use for the condition in the Pharmacological Treatment section on page 1 of the Louisiana Opioid Analgesic Treatment Worksheet.

Enter the prior drug or drugs, dose, duration, and date of each trial.

Denial Risk

Missing Louisiana Worksheet

Requests submitted without the required Louisiana Opioid Analgesic Treatment Worksheet will not be approved.

This applies to opioid prior authorization requests and quantity-limit override requests.

Denial Risk

Long-Acting Opioid Use Inconsistent with Criteria

A long-acting opioid request may be denied when use is inconsistent with the criteria or when required attestations are not supported.

The requested medication must be for continuous, around-the-clock analgesia when alternatives are inadequate or not tolerated.
Do not prescribe for acute pain, mild pain, pain not expected to persist for an extended period, or as-needed (PRN) analgesia.
Review the requested product's prescribing information; explain in writing any unanswered or unsupported required statement.

Denial Risk

Nonpreferred Long-Acting Opioid Without Exception

A nonpreferred long-acting opioid may be denied when the individual has not tried and failed or not tolerated two preferred long-acting agents and no documented exception applies.

Preferred agents are morphine sulfate ER (generic MS Contin) and fentanyl patch.

Denial Risk

Exceeds Quantity or MED Limit

Requests exceeding state quantity limits or 90 mg morphine equivalent dose (MED) per day require an approved override and supporting documentation.

The 90 mg MED/day limit applies to opioid-naive and opioid-tolerant individuals.
Quantity limits apply to all opioids under HPA16-35; listed short-acting opioids are also subject to HPA17-7.
For opioid-naive recipients, short-acting opioid supplies are limited to 28 tablets or capsules per 7-day supply within a 30-day period.

Opioid-naive and opioid-tolerant individuals

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, relevant respiratory-depression and interaction risks, risks of combining opioids with central nervous system depressants, and opioid abuse or overdose risk have been discussed.

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

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

title":"Initial opioid therapy"},{

Initial long-acting opioid therapy

Initial long-acting opioid therapy requires all additional long-acting criteria.

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 short-acting opioids for this condition for at least two weeks.At least two weeks
Enter the drug, dose, duration, and date of the trial in the Pharmacological Treatment section of page 1 of the Louisiana Opioid Analgesic 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 analgesic.
The prescriber has thoroughly reviewed the prescribing information for the requested product.

title":"Initial long-acting opioid therapy"},{

State quantity limits

Long-acting opioidsSubject to quantity limits set by the State under HPA16-35

Listed short-acting opioidsSubject to quantity limits set by the State under HPA16-35

Override processQuantity-limit overrides must be requested using the Louisiana Opioid Analgesic Treatment Worksheet