Mass General Brigham Health Plan Opioid Prior Auth

Coverage Criteria for Opioid Products

Short-Acting Opioids

Authorization may be granted when ONE of the following criteria is met:

Cancer or end-of-life: Member has a diagnosis of cancer or is receiving opioids as part of end-of-life care.

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Postoperative pain: Medication is being used to treat postoperative pain AND medication is not being prescribed for pain related to a dental procedure AND the dose being prescribed is the dose the patient was stable on prior to discharge AND prescriber certifies there is an active treatment plan that includes a specific treatment objective and other pharmacologic and non-pharmacologic agents as appropriate.

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Other diagnoses: Medication is requested for other diagnoses AND prescriber certifies an informed consent document has been signed, an addiction risk assessment has been performed, and a written/signed agreement between prescriber and patient addressing opioid therapy is in place.

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Long-Acting Opioids

Authorization may be granted when ALL of the following are met for specified diagnoses and trials:

Diagnoses qualifying for long-acting opioids: Member has ONE of the following diagnoses: diagnosis of cancer OR member is receiving opioids as part of end-of-life care OR for other diagnoses meeting the criteria below.

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Other diagnoses requirements: For non-cancer/end-of-life diagnoses: member has moderate to severe chronic non-neuropathic pain OR moderate to severe neuropathic pain/fibromyalgia AND required prior trials (e.g., adequate response to 8 weeks of gabapentin titrated to a therapeutic dose or contraindication; for neuropathic pain an adequate 6-8 week trial of a tricyclic antidepressant) with documentation of drug(s), dose, duration, and dates of trial.

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Use restrictions: Requested long-acting opioid will NOT be used as an as-needed (PRN) analgesic, will NOT be used for pain that is mild or not expected to persist, and NOT for acute pain. For postoperative pain, use is allowed only if the member was already receiving chronic opioid therapy prior to surgery or if postoperative pain is expected to be moderate-to-severe and persist for an extended period.

Butrans / Belbuca

Authorization may be granted when ONE of the following criteria is met:

Cancer or end-of-life: Member is being treated for cancer-related pain or end-of-life pain.

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Other diagnoses: Member has pain severe enough to require daily, around-the-clock, longer-term opioid treatment AND the requested drug will NOT be used as an as-needed PRN analgesic, will NOT be used for pain that is mild or not expected to persist, will NOT be used for acute pain, will NOT be used concurrently with other long-acting opioids, and will NOT be used for opioid dependence.

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Opioid Cough Medications

Authorization may be granted when ALL of the following criteria are met:

Age requirement: Member is 18 years of age or older.

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Dose/quantity override: If requesting greater than the maximum dose or quantity specified in product prescribing information or compendia for off-label uses, the request must involve an FDA‑approved indication (for on‑label) or meet off‑label guideline approval criteria and be supported by compendia (for off‑label).

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Prior use or clinical justification: Maximum doses specified under the quantity restriction have been tried for an adequate period and deemed ineffective OR there is clinical support that lower doses would be ineffective; higher dose/quantity is supported by compendia or manufacturer prescribing information.

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Continuation of Therapy

Reauthorizations must meet initial criteria and additional continuation requirements:

General reauthorization: Reauthorizations for short-acting opioids must meet all initial criteria. Reauthorizations for long-acting opioids, Butrans, and Belbuca may be granted when the member is requesting medication for cancer or end-of-life care OR when continuation documentation for other diagnoses is provided as below.

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Continuation documentation for non-cancer diagnoses: For all other diagnoses, documentation must address ALL of the following: treatment goals defined including estimated duration; treatment plan includes a nonopioid analgesic and/or nonpharmacologic intervention; member demonstrates meaningful improvement in pain and function on a validated instrument (e.g., Brief Pain Inventory); member screened for substance abuse/opioid dependence using a validated instrument (e.g., DAST-10); rationale for not tapering/discontinuing; and screening for comorbid mental health.

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This policy does not support use of long-acting opioids or buprenorphine transdermal/film (Butrans/Belbuca) as PRN (as‑needed) analgesics. Requests where the medication is intended for intermittent or as‑needed use should not be authorized under the chronic/around‑the‑clock criteria described for long‑acting agents or buprenorphine products. Do not approve when the clinical indication is for mild or short‑duration pain or for acute pain that is expected to resolve quickly; the policy explicitly excludes these situations for long‑acting opioids and Butrans/Belbuca. Additionally, Butrans/Belbuca are not to be used for treatment of opioid dependence under this policy.

The policy explicitly lists several inappropriate indications for authorization: use as an as‑needed (PRN) analgesic; treatment of mild pain or pain not expected to persist; and treatment of acute pain. For postoperative pain, coverage is limited — long‑acting opioids and buprenorphine products are only appropriate when the member was already receiving chronic opioid therapy prior to surgery or when postoperative pain is expected to be moderate‑to‑severe and persist for an extended period. For Butrans/Belbuca, the policy also disallows concurrent use with other long‑acting opioids and use for opioid dependence.

Initial Therapy Requirements

Initial therapy requirements for long-acting opioids

Prior short-acting opioid trial: For members filling the prescribed long-acting opioid for the first time, prior to the start of therapy the member has failed an adequate (minimum 4 week) trial of a short-acting opioid (document drug(s), dose, duration, and date) OR the member is already established on the prescribed medication and this is continuation of therapy.4 weeks

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Nonopioid alternative trials: Adequate response to 8 weeks of gabapentin titrated to a therapeutic dose OR contraindication to gabapentin; for neuropathic pain, adequate response to at least 6-8 weeks of a tricyclic antidepressant titrated to a therapeutic dose (e.g., amitriptyline, nortriptyline, imipramine); document drug(s), dose, duration, and date of trial.6-8 weeks / 8 weeks

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Continuation / Reauthorization Criteria

Continuation Therapy Durations

Reauthorization durations:

Cancer/end-of-life continuation: For diagnosis of cancer or end-of-life care: reauthorization may be granted for 12 months.12 months

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Other diagnoses continuation: For long-acting opioids, Butrans, and Belbuca for all other diagnoses: reauthorization may be granted for 6 months provided continuation criteria are met.6 months

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Postoperative initial approval duration: For diagnosis of postoperative pain management (initial approvals): 14 days.

Step Therapy and Required Trials

Required prior trials / conditions	Notes
Prior trial of a short-acting opioid (adequate minimum 4‑week trial) for members starting a long-acting opioid	Document drug(s), dose, duration, and dates of the trial; applies when member is filling the prescribed medication for the first time
Established on the prescribed long-acting opioid (continuation of therapy)	If member is already established on the medication, continuation may be approved instead of requiring a new short-acting opioid trial
For non-cancer/non–end-of-life diagnoses: required nonopioid trials for neuropathic pain	Adequate response to 8 weeks of gabapentin titrated to therapeutic dose OR 6–8 week trial of a tricyclic antidepressant (e.g., amitriptyline, nortriptyline, imipramine); document drug(s), dose, duration, and dates
Product-specific trial/failure requirements	Certain ER products listed require trials or failures of preferred alternatives; Nucynta requires trial and failure (or contraindication/intolerance) to at least two preferred products. Listed products include Hydromorphone ER, Nucynta, Morphine sulfate ER, Oxymorphone ER, Hysingla ER, Oxycontin, Xtampza ER

Quantity Limits and Overrides

Opioid cough medications — quantity limits and overrides

ScopeMaximum product-specific quantity limits apply to opioid-containing cough medications; standard quantity restrictions are enforced.

Override requirementsRequests to exceed the maximum dose or quantity require an FDA‑approved indication and must be supported by product labeling or an accepted compendium (e.g., AHFS, DRUGDEX).

Off‑label overridesQuantity limit overrides for off‑label indications must meet off‑label guideline approval criteria and be supported by compendia evidence.

Clinical trial of lower dosesBefore approving an override, documentation should show maximum doses under the quantity restriction were tried and were ineffective, or there is clinical rationale why lower doses would be ineffective.

Age restriction contextPolicy applies to adult members (member must be 18 years of age or older to qualify for opioid cough medication authorization).

Provider Actions: Authorization, Documentation, and Denials

Prior Authorization

Prior Authorization Required

Prior authorization is required for short-acting and long-acting opioids, BuTrans/Belbuca patches, and opioid cough medications. Requests must meet the specific diagnostic and utilization criteria for the drug class (e.g., cancer or end-of-life care, postoperative pain per policy, or appropriate chronic pain diagnoses) and may require documentation of prior trials or exemption reasons.

Applies to short-acting opioids, long-acting opioids, BuTrans/Belbuca (buprenorphine patch), and opioid-containing cough products.
Contact for prior authorization: All Plans Phone: 877-519-1908; Fax: 855-540-3693 (specialty and pharmacy contact numbers in source).

Step Therapy

Step Therapy and Required Trials

For certain long-acting opioids, members must have trials of specified alternatives or documentation of contraindication/intolerance before approval. Examples include a minimum 4-week trial of a short-acting opioid prior to initiation, an adequate 6–8 week trial of gabapentin titrated to therapeutic dose for non-neuropathic pain, and a 6–8 week trial of a tricyclic antidepressant for neuropathic pain or fibromyalgia when applicable. Some agents (e.g., Nucynta) require trials of two preferred products.

Approval Durations and Coding Notes

Initial approval durations

Postoperative pain initial approval14 days

Cancer or end-of-life initial approval12 months

All other diagnoses initial approval6 months

Opioid cough medications (off-label or exceeding limits)60 days

Background

This policy governs prior authorization and coverage conditions for opioid agents across indications including cancer and end‑of‑life pain, selected postoperative situations, and chronic non‑neuropathic and neuropathic pain. It separates short‑acting and long‑acting opioid requirements, and applies specific product rules for buprenorphine transdermal/film (Butrans/Belbuca). Key clinical boundaries include that long‑acting opioids and Butrans/Belbuca are intended for daily, around‑the‑clock, longer‑term opioid treatment (or cancer/end‑of‑life care) and are not appropriate for PRN, mild, short‑duration, or typical acute pain scenarios. For chronic non‑cancer pain, the policy requires documented prior trials of indicated nonopioid and opioid therapies (for example, adequate trials of gabapentin or tricyclic antidepressants for neuropathic pain) and documentation of drug, dose, duration, and dates of prior trials before authorization is granted.

Definitions and Reauthorization Notes

Reauthorization / Continuation of therapy requirements

General requirementReauthorization requires documentation that the initial criteria remain met and that treatment goals are defined, including estimated duration.

Functional improvementMember must demonstrate meaningful improvement in pain and function using a validated instrument (e.g., Brief Pain Inventory).

Risk screening and rationaleMember must be screened for substance abuse/opioid dependence with a validated instrument (e.g., DAST-10), have rationale documented for not tapering, and be screened for comorbid mental health conditions.

Nonopioid interventionsFor non-cancer diagnoses, the treatment plan must include use of a nonopioid analgesic and/or nonpharmacologic intervention.

OpenPayer

Opioid Risk Management — Prior Authorization and Quantity Limits

Coverage Criteria for Opioid Products

Initial Therapy Requirements

Continuation / Reauthorization Criteria

Step Therapy and Required Trials

Quantity Limits and Overrides

Provider Actions: Authorization, Documentation, and Denials

Approval Durations and Coding Notes

Background

Definitions and Reauthorization Notes