CurrentMass General Brigham Health PlanPolicy N/A

Opioid Quantity Limits

Defines prior authorization and quantity limit override criteria for single-opioid products without an FDA maximum dose for Mass General Brigham Health Plan commercial/exchange pharmacy benefit members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyOpioid Quantity Limits

Policy CodePolicy N/A

Change TypeAdded (policy created)

Effective DateJan 1, 2024

Next Review Date

Key ActionSubmit prior authorization request for single-opioid products without an FDA maximum dose; authorization may be granted for members new to the plan who are currently receiving treatment, excluding samples or manufacturer assistance program supplies.

SourceLink

POLICY UPDATE CHANGES

Policy created adopting Optum Opioid Quantity Limit Overrides guidelines.

1Plan Types Specified

2Program Types

2Initial Approval Durations

Coverage Summary & Scope

Coverage is covered_with_criteria for single-opioid products without an FDA maximum dose under the Pharmacy Benefit. Effective date: 01/01/2024. Prior authorization is required for quantity limit overrides; authorization may be granted for members new to the plan who are currently receiving treatment with the requested medication (excluding samples or manufacturer patient assistance program supplies).

Authorization Criteria

Authorization may be granted for members new to the plan who are currently receiving treatment with the requested medication, excluding when the product is obtained as samples or via manufacturer's patient assistance programs. OR Authorization may be granted when the following criteria is met:

ONE of

Member has diagnosis of malignant cancer pain
All other diagnoses must meet ALL of the following
- Requested medication is prescribed by a pain specialist or by pain management consultation
- ALL of the following
  - An appropriate patient medical history and physical examination
  - A description of the nature and intensity of the pain
  - Documentation of appropriate dose escalation
  - Documentation of ongoing, periodic review of the course of opioid therapy
  - An updated, comprehensive treatment plan stating objectives to determine treatment success (e.g., pain relief or improved physical and/or psychosocial function)
  - Verification that the risks and benefits of the use of the controlled substance have been discussed with the patient, significant other(s), and/or guardian

Provider Requirements & Actions

Prior Authorization

Prior authorization required for quantity limit override

Submit prior authorization request for single-opioid products without an FDA maximum dose; authorization may be granted for members new to the plan who are currently receiving treatment, excluding samples or manufacturer assistance program supplies.

Documentation Required

Chart documentation required for non-malignant diagnoses

For non-malignant diagnoses the prescriber must be a pain specialist or have performed a pain management consultation and must provide chart documentation including medical history/physical exam, pain description, dose escalation, periodic review, updated treatment plan with objectives, and verification that the risks and benefits of the use of the controlled substance have been discussed with the patient, significant other(s), and/or guardian.

Billing Rule

Benefit applicability

This override policy applies to the Pharmacy Benefit only (not Medical Benefit).

Background & Definitions

This policy defines criteria for overriding opioid quantity limits for single opioids that do not have an FDA-maximum dose. For opioids that do have an FDA maximum dose (for example, APAP-containing opioid products), follow the standard Quantity Limit Override criteria or the drug-specific guideline as applicable.

Single opioids without an FDA-maximum dose: Opioid products that do not have an FDA-specified maximum dose; this policy governs quantity limit overrides for these products.