Opioid Prescription Prior Authorization
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Defines MedStar Family Choice DC requirements for prior authorization of opioid prescriptions, including limits, exemptions, documentation, and review processes for enrolled members and providers.
Subsection 1.2.2 reworded for clarity and buprenorphine products for chronic pain added to list of extended-release/partial agonist opioids subject to PA.
Defined Medical Reviewer and Opioid naïve; added statement that all opioid prescriptions require PA unless exception criteria are met.
Added reasons an opioid request may be denied even if other policy requirements are met, including prescriptions issued out of scope of prescriber.
Removed redundant section requiring all opioid requests be evaluated by a Medical Reviewer.
Removed detailed subsections about early refills (6.1 and 6.2) that are covered in Policy 204.DC.
Coverage Criteria
Authorization and review criteria
Covered when ALL of the following are met
PBM may automate screening for opioid-naïve prescriptions that meet SUPPORT Act limits
Supports automated SmartPA processing
Includes verification of established opioid regimen when applicable
The following enrollee categories are exempt from prior authorization for opioid prescriptions: those undergoing active cancer treatment, enrollees with sickle cell disease who have not received gene therapy, those receiving hospice or palliative care, and residents of long-term care or skilled nursing facilities. In addition, opioid‑naïve enrollees whose prescriptions meet SUPPORT Act limits (≤50 MME/day and no more than a 7‑day supply for adults or a 3‑day supply for enrollees under 18) are also exempt from PA requirements.
Requests that lack required documentation or that cannot be validated may be denied. All opioid PA requests must include supporting medical records and a completed Opioid Prior Authorization form; incomplete forms or missing clinical documentation may result in denial. The prescriber must attest to PDMP review, annual random urine drug screening (with specified discharge exceptions), offering/providing naloxone, and inclusion of a signed patient‑provider pain agreement when required. MedStar Family Choice DC may also deny a request if a clinical or safety concern cannot be resolved or if the prescription cannot be validated as issued in the usual course of professional treatment (for example, when a prescriber writes for an indication outside their scope).
Coding and Limits
Provider Actions and Requirements
Prior authorization required; PBM SmartPA may automate SUPPORT Act screening
Prior authorization is required for all opioid prescriptions; the PBM performs automated SmartPA screening to identify opioid‑naïve fills that meet SUPPORT Act minimum standards (≤50 MME/day and supply limits) and may allow those fills without a manual PA.
No step therapy pathways
There are no step therapy pathways specified in this policy.
Required medical records and completed Opioid PA form
All opioid PA requests must include supporting medical records and a completed Opioid Prior Authorization form; incomplete forms or missing supporting documentation may result in denial.
- Prescribers must submit the completed Opioid Prior Authorization form available on the MedStar Family Choice DC provider website.
- The PA form requires attestations including PDMP review in CRISP, annual random urine drug screening (with exemptions for ≤30‑day discharge supplies), naloxone offered/prescribed, and a signed patient‑provider pain management agreement when applicable.
- Incomplete PA forms or forms submitted without supporting clinical documentation may be denied.
Denial triggers: unresolved safety concerns or invalid prescriber scope
Requests may be denied when clinical or safety concerns cannot be resolved, when the prescription cannot be validated as issued in the usual course of professional treatment, or when the prescriber’s scope does not cover the indication.
- Denial may occur if a clinical or safety concern is identified and cannot be resolved even if other authorization parameters are met.
- Denial may occur if unable to validate the prescription as issued in the usual course of professional treatment (for example, prescriptions written for indications outside the prescriber’s scope).
Initial Therapy Limits
Initial therapy limits — opioid-naïve dispensing limits
Opioid-naïve dispensing limits
Meets SUPPORT Act minimum standards and may be processed by PBM automation
Definitions
Background
This policy implements the federal SUPPORT Act minimum standards for opioid prescribing by establishing automated and manual safety checks. Key controls include an MME threshold of ≤50 morphine milligram equivalents per day for opioid‑naïve enrollees and supply limits of no more than a 7‑day supply for adults and a 3‑day supply for enrollees under 18. PBM SmartPA may screen and allow fills that meet these SUPPORT Act limits without manual prior authorization. Additional safety measures required on the PA form include PDMP review, documentation of at least annual random urine drug screening (with a discharge supply exception ≤30 days), and that the prescriber has provided or offered naloxone to the enrollee or household.
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