Opioid Products Indicated for Pain Management — Prior Authorization Criteria
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Defines prior authorization (PA) requirements, clinical criteria, limits, and documentation expectations for opioid products used for pain management under Kansas Medicaid.
As of April 16, 2025, some products (e.g., certain Xtampza ER and Tapentadol entries) are noted as not Medicaid eligible
Minor changes: April 16, 2025
Coverage and Indication-Based Criteria
Coverage criteria by indication
Covered when the stated conditions for the clinical context are met. Prior authorization (PA) is required where noted.
Diagnosis-limited approvals; see product-specific restrictions.
PA required to exceed 14 days cumulative in 60 days.
These attestation and documentation elements govern PA approvals for extended acute prescriptions.
Renewal/ongoing documentation requirements apply.
Applies to initiation/escalation to long‑acting formulations.
MME-based coverage criteria
Coverage and utilization management apply according to per‑product MME conversion factors and the per‑day MME and unit/day limits in the tables.
Providers must apply the listed conversion factors when calculating daily MME.
Dose optimization limits (units/day) are enforced for ER/LA products.
Patch multipliers and day‑supply adjustments are required for accurate MME/day comparisons.
For patients with cancer, sickle cell disease, hospice/palliative care, or those residing in assisted/custodial care, Trans‑mucosal Immediate Release Fentanyl (TIRF) products are approved only for a cancer diagnosis and prescribers must attest to REMS enrollment prior to prescribing TIRF. Fentanyl transdermal patches are limited to patients with cancer or palliative care‑related pain, and methadone is limited to terminal cancer pain. Conversely, methadone and fentanyl products are not covered for acute non‑cancer pain (see acute pain and chronic pain criteria for exception pathways and prior authorization requirements).
Three buprenorphine formulations that carry an FDA‑approved indication for Medication Assisted Treatment (MAT) are explicitly identified in the policy as excluded from Medicare’s opioid overutilization reporting. These MAT‑indicated buprenorphine products are treated separately from the pain‑management opioid criteria in this policy and are not subject to the same utilization‑management reporting described for other opioid formulations.
Use of methadone or fentanyl products for acute or chronic non‑cancer pain is restricted and may be considered not covered outside the specified diagnostic indications. For acute non‑cancer pain, methadone and fentanyl products are not covered and initial opioid fills are limited (see acute limits); for chronic non‑cancer pain the policy reiterates that methadone and fentanyl are not covered for chronic pain except where diagnosis‑limited cancer or palliative exceptions apply. Providers requesting coverage outside those indications must follow the prior authorization pathways and meet the conservative therapy, documentation, and monitoring requirements outlined in the policy.
Product Lists, Codes, and Conversion Factors
| Buprenorphine | Butrans, Belbuca (included) |
| Fentanyl transdermal | Duragesic (included) |
| Hydrocodone ER | Zohydro ER, Hysingla ER (included) |
| Hydromorphone ER | Exalgo (included) |
| Methadone | included with diagnosis restrictions |
| Morphine CR/ER | Kadian ER, Avinza, MS Contin, Oramorph, Arymo ER (included) |
| Morphine/Naltrexone | Embeda (included) |
| Oxycodone ER | OxyContin; Xtampza ER noted (#) (included) |
| Oxycodone/Naloxone | Targiniq ER (included) |
| Oxycodone/Naltrexone | Troxyca ER (included) |
| MME conversion table | Detailed per-agent MME conversion factors (e.g., hydrocodone 1, oxycodone 1.5, fentanyl patch factor 7.2, buprenorphine patch 12.6, methadone 4.7, etc.) |
| Apadaz (benzhydrocodone/APAP) | MME conversion factor 1.2; 90 MME/day dose equivalent = 75 mg |
| Actiq (fentanyl) | MME conversion factor 0.13; 90 MME/day dose equiv = 600 mcg |
| Fentora (fentanyl) | MME conversion factor 0.13; 90 MME/day dose equiv = 700 mcg |
| Lazanda (fentanyl nasal) | MME conversion factor 0.16; 90 MME/day dose equiv = 600 mcg |
| Subsys (fentanyl film/oral spray) | MME conversion factor 0.18; 90 MME/day dose equiv = 500 mcg |
| Hydrocodone/APAP | MME conversion factor 1; 90 MME/day = 90 mg |
| Hydromorphone (Dilaudid) | MME conversion factor 5; 90 MME/day = 18 mg |
| Levorphanol | MME conversion factor 11; 90 MME/day = 8 mg |
| Meperidine | MME conversion factor 0.1; 90 MME/day = 600 mg |
| Morphine IR | MME conversion factor 1; 90 MME/day = 90 mg |
Prior Authorization, Documentation, and Prescriber Requirements
PA required for acute exceedances and most chronic/long-acting use
Prior authorization (PA) is required to exceed initial acute-use allowances and for many chronic or long-acting opioid uses. Specifically: no PA is required for prescriptions that are equal to or for no more than a cumulative 14-day supply of opioids in the last 60 days within allowed limits (maximum 7-day supply per fill). PA is required to exceed 14 cumulative days in 60 days, to exceed a 90-day supply for chronic use, and for long-acting opioid requests subject to the long-acting criteria and trials described in the policy.
- Initial no-PA allowance: cumulative ≤14 days in past 60 days; max 7 days per fill (acute).
- PA required to exceed 14-day cumulative supply in 60 days (acute exceedance).
- PA required to exceed 90-day supply for chronic therapy; long-acting opioids have additional PA requirements.
PA/monitoring when doses exceed table MME/day or unit limits
PA or utilization management review applies when prescribed doses exceed the per-product MME/day limits or when unit/day dose-optimization limits shown in the tables are surpassed. Providers should expect authorization/monitoring if calculated MME/day is above the listed 90 MME/day equivalences for a given product or if unit/day optimization constraints for long-acting agents are exceeded.
- Dose comparisons are made using the MME conversion factors and the 90 MME/day equivalence entries in Table 3a and the long-acting tables.
- Long-acting exceptions and optimization/unit limits are in Table 2b and Table 3b; exceeding those entries may trigger PA.
- Examples and exact per-product limits are listed in the tables (short-acting and long-acting).
Documented trials required before escalation or long-acting opioids
Before escalation to extended acute supplies or initiation of long-acting opioids, document trials of at least two non-opioid ancillary treatments (e.g., NSAIDs, acetaminophen, antidepressants) within the last 90 days unless contraindicated. For long-acting opioid requests, document failure/intolerance/contraindication to at least two preferred short-acting opioids and trial of >30 days of short-acting opioid in the last 60 days; trials of two preferred long-acting agents are required before non-preferred long-acting use unless intolerant.
- Acute exceedance: ≥2 non-opioid ancillary treatments tried in last 90 days (unless contraindicated).
- Long-acting initiation: documented failure/contraindication to ≥2 preferred short-acting opioids and receipt of short-acting opioid >30 days in last 60 days.
- Long-acting non-preferred: trial and failure of ≥2 preferred long-acting opioids required before non-preferred use; one-time one-month override allowed for tapering.
Use table dose-optimization/unit limits as utilization controls
Dose-optimization/unit limits in the tables function as utilization controls. For example, Butrans® buprenorphine patch is limited to 1 unit per 7 days; other long-acting products have specified unit/day restrictions that must be followed prior to approving higher quantities.
- Butrans (buprenorphine patch) dose-optimization limit = 1 unit/7 days.
- Table 2b and long-acting tables list unit/day optimization limits (e.g., specified units/day for ER products).
Complete required clinical documentation and attestations
Maintain and submit required documentation with PA requests: defined treatment duration and goals, rationale for not tapering (when applicable), a pain management/opioid agreement, plan for random urine drug screening, PDMP (K-TRACS) review attestation, screening for substance use and depression, and documentation of required trials/failures of preferred agents.
- Document treatment duration and goals and provide rationale if not tapering or discontinuing therapy.
- Include a pain management/opioid agreement and plan for random urine drug screens.
- Attest to PDMP (K-TRACS) review and document screening for substance use disorder and depression; if positive for depression, document treatment.
- Document trials/failures or contraindications to required agents per long-acting/ chronic criteria.
Set patch Day Supply to wear-time (buprenorphine ×7; fentanyl ×3)
Adjust Day Supply for transdermal patch prescriptions so MME/day calculations reflect typical wear time: set Day Supply = number of buprenorphine patches × 7 days and Day Supply = number of fentanyl patches × 3 days before calculating MME/day or submitting PA.
- Buprenorphine patches: Day Supply = # patches × 7 (conversion multiplier 12.6 used in MME calculations).
- Fentanyl patches: Day Supply = # patches × 3 (conversion multiplier 7.2 used in MME calculations).
Denial triggers: day supply, >90 MME/day, disallowed methadone/fentanyl indications
Requests that exceed allowed day supply limits, exceed 90 MME/day, or request methadone or fentanyl products for acute or chronic non-cancer indications may be denied. Denials may also result if required conservative therapy trials or documentation/attestations are not provided.
- Exceeding allowed total day supply (e.g., >21 days for some acute requests) is a denial trigger.
- Exceeding 90 MME/day may lead to denial or require additional attestation and documentation.
- Requests for methadone or fentanyl for acute or non-cancer chronic pain (outside specified indications like cancer/palliative/hospice) are not covered and may be denied.
Exceeding per-product or cumulative MME/day may trigger PA/UM
Exceeding the listed per-product MME/day limits for short-acting opioids (as shown in Table 3a) may prompt utilization management review or PA. Calculate total daily MME for all concurrent opioid medications and compare to the 90 MME/day threshold and product-specific 90 MME equivalents.
- Use Table 3a conversion factors to determine each product’s 90 MME/day equivalent.
- Prescriber should calculate total MME/day for concurrent opioid medications; exceeding listed limits may trigger PA/UM.
Exceeding long-acting unit/day optimization limits can trigger PA/denial
Dispensing more units per day than the dose-optimization/unit limits for long-acting opioids (e.g., exceeding specified units/day in Table 2b/3b) may trigger PA or denial. Providers must follow the unit/day constraints in the long-acting tables when prescribing ER/LA products.
- Follow unit/day optimization limits in Table 2b and long-acting product tables (examples: unit/day limits listed for OxyContin, MS Contin, Zohydro, etc.).
- Requests exceeding those unit/day limits are subject to PA or denial.
Non-Opioid Trials and Step Therapy Requirements
Documented trial and failure or contraindication required for escalation to longer durations or long-acting products
Documented trials or documented contraindications/intolerances are required before approving extensions in duration or escalation to long‑acting formulations.
This requirement is needed for PA approval to extend acute therapy beyond the no‑PA allowance.
Part of the chronic PA bundle of requirements.
Evidence of recent short‑acting use plus trials is required prior to long‑acting use.
Initial approval duration for long‑acting opioids when criteria met is typically 3 months.
Day Supply and Fill Limits
Key Definitions Used in This Policy
Clinical and Policy Background
This policy manages opioid prescribing with three primary safeguards: dose limits expressed as morphine milligram equivalents (maximum cumulative dose: 90 MME/day), limits on acute treatment duration (including an initial no‑PA allowance of up to a cumulative 14 days within 60 days and a maximum 7‑day supply per fill), and additional authorization, trial, and documentation requirements when therapy extends into chronic use. Specific product classes (e.g., long‑acting formulations, fentanyl transdermals, methadone, and TIRF) have diagnosis‑limited approvals and additional utilization controls to reduce harm in non‑cancer populations.
Imaging (If Applicable)
No explicit imaging requirement stated
The policy does not specify any required imaging studies for PA or approval; imaging requirements are not stated in the document.
- Imaging requirements are not specified in the policy text for opioid PA requests (chunk 10).
Explicit Non‑Coverage Statements
NOT COVERED: Methadone and fentanyl products for acute non‑cancer pain are not covered under this policy. Additionally, Trans‑mucosal Immediate‑Release Fentanyl (TIRF) products are only approved for patients with a diagnosis of cancer and therefore are not covered for non‑cancer indications. Requests outside these specified indications may be denied unless the patient meets the narrow cancer, sickle cell, hospice/palliative, or institutionalized criteria and required attestations (e.g., REMS enrollment for TIRF) are documented.
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