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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsMedStar Opioid Prior Auth Coverage | OpenPayer
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    CurrentMedStar Family Choice MarylandPolicy 218

    Opioid Prescription Prior Authorization

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    This policy governs evaluation and prior authorization of opioid medication requests for MedStar Family Choice Maryland members. It establishes utilization, safety, documentation, exemption, denial, and prescriber-network requirements for opioid coverage.

    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyOpioid Prescription Prior Authorization
    Policy CodePolicy N/A
    Change TypeMaterial revision
    Effective Date07/2025
    Next Review DateN/A
    Key ActionSubmit medical records and a completed opioid prior authorization form for every opioid authorization request.
    SourceLink
    POLICY UPDATE CHANGES

    The 2025 revision updated regulatory references to current MCO standards and Maryland requirements.

    Buprenorphine products indicated for chronic pain were expressly added to the extended-release opioid review category.

    The term "managed drug limits" was removed because it was duplicative of formulary quantity limits.

    The reference for early refills of controlled medications was updated to Pharmacy Policy 204.

    All opioidsOpioid prior authorization
    50 MME/dayDaily limit
    7 days

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Adult supply limit
    3 daysUnder-18 supply limit
    24 hoursDecision timeframe
    30 daysOut-of-network exception

    Opioid Coverage Criteria

    Standard Opioid Authorization

    Prior authorization is required for all opioid medication requests. Initial authorization review is automated by the Pharmacy Benefits Manager (PBM) to screen for compliance with SUPPORT Act minimum standards.

    Automated PBM screening standards

    • The prescribed opioid dose is no more than 50 morphine milligram equivalents (MME) per day.<= 50 MME/day

    • Supply limit

      • The prescription is for no more than a seven-day supply for an adult member.<= 7 days
      • The prescription is for no more than a three-day supply for a member under 18 years of age.<= 3 days
    MedStar Family Choice may deny an opioid request when a clinical or safety concern is identified and cannot be resolved, even when other authorization parameters are met.
    MedStar Family Choice may deny a request when it cannot validate that the prescription was issued in the usual course of professional treatment within the intent of the Maryland Controlled Dangerous Substances Act, Criminal Law Article, §§ 5-501–5-505, Annotated Code of Maryland.
    This validation concern includes prescriptions written for an indication outside the prescriber's scope, such as an oncologist prescribing opioids for pain unrelated to a cancer-related diagnosis.

    Medical Reviewer Review

    Medical Reviewer review is required for the following opioid requests:

    Requests requiring Medical Reviewer review

    • Immediate-release opioids

      • The immediate-release opioid prescription, or combination of prescriptions, exceeds 50 MME per day.> 50 MME/day

      • Supply exceeds applicable limit

        • The prescription exceeds a seven-day supply for an adult member.> 7 days
        • The prescription exceeds a three-day supply for a member under 18 years of age.> 3 days

    Prior Authorization Exemptions

    The following patients or prescriptions are exempt from opioid prior authorization requirements:

    Exempt patients or prescriptions

    • The patient is undergoing active cancer treatment.
    • The patient has sickle cell disease and has not received gene therapy, such as Casgevy (exagamglogene autotemcel), Lyfgenia (lovotibeglogene), or similar gene therapy.
    • The patient is receiving hospice care.
    • The patient is receiving palliative care.
    • The patient resides in a long-term care facility or skilled nursing facility.

    • Opioid-naive member exception

    Documentation and Monitoring

    All opioid prior authorization requests must include the required documentation and prescriber attestations. Incomplete submissions or submissions without supporting clinical documentation may result in denial.

    Documentation and monitoring requirements

    • Medical records supporting the request are submitted.
    • A completed Opioid Prior Authorization form is submitted for the opioid request. The form is available on the MedStar Family Choice provider website: Opioid Prior Authorization Form.
    • The prescriber attests that the Controlled Substance Prescription Drug Monitoring Program (PDMP) was reviewed in CRISP.
    • The patient has had or will have a random urine drug screen at least annually.

    Opioid prior authorizations requested by out-of-network (OON) outpatient physicians are not covered by MedStar Family Choice. A Medical Reviewer may grant a one-time exception for a 30-day supply when a continuity relationship can be established between the member and the OON prescriber. This exception is intended to allow the member time to obtain future services and prescriptions from an in-network provider without a gap in care. Patients will be referred to a Care Manager for assistance establishing care with an in-network provider.

    MedStar Family Choice will not authorize an early refill of controlled medications except as outlined in Pharmacy Policy 204: Early Refill, Lost Medication, & Travel Supply, Section 4.

    Under Maryland Medicaid Pharmacy Program Advisory No. 94, Medicaid patients should not pay cash for prescriptions under normal circumstances, especially prescriptions for controlled substances. Recipients who insist on paying cash for controlled-substance prescriptions should be referred to the Medicaid Recipient Fraud and Abuse Department. Report concerns to the Office of the Inspector General Recipient Fraud/Abuse Hotline at 866-770-7175 or www.dhmh.state.md.us/oig.

    Initial Therapy

    Opioid-Naive Initial Therapy

    An opioid-naive member may receive an exempt initial prescription only when all of the following are met.

    Opioid-naive initial supply

    • The member has not been dispensed an opioid prescription through the pharmacy benefit during the previous 30 days.
    • The ordered opioid prescription does not exceed 50 MME per day.≤ 50 MME/day
    • The prescription does not exceed the applicable cumulative day-supply limit.≤ 7 cumulative days for adults; ≤ 3 cumulative days for members under 18

    Continuation and Established Therapy

    Extended-Release Opioid Continuation

    Continuation or established-regimen evidence is required for extended-release opioid therapy.

    Established extended-release opioid regimen

    • The patient is on an established opioid regimen confirmed by prescription claims history or clinical documentation.Established opioid regimen

    Quantity and Dose Limits

    Opioid-naive members
    Daily limitNo more than 50 MME per day
    Member groupOpioid-naive members
    Review implicationRequests exceeding 50 MME per day require Medical Reviewer review
    Adult opioid supply
    Maximum supplyNo more than a seven-day supply
    Member groupAdults
    Review implicationRequests exceeding seven days require Medical Reviewer review

    Dose, Supply, and Monitoring Parameters

    Daily morphine milligram equivalent
    Standard threshold≤ 50 MME per day
    Applies toOpioid-naive members and standard opioid authorization screening
    Above thresholdRequests exceeding 50 MME per day require Medical Reviewer review
    Adult opioid supply
    Standard maximum≤ 7 days
    Applies toAdults
    Above limitRequests exceeding the seven-day supply limit require Medical Reviewer review

    Submission, Review, and Denial Risks

    Prior Authorization

    Prior Authorization Required for All Opioids

    Prior authorization is required for all opioid medications. The Pharmacy Benefits Manager (PBM) automatically screens opioid prescriptions for SUPPORT Act limits, including a maximum of 50 MME per day and supply limits of seven days for adults or three days for members under age 18.

    • All opioids require prior authorization.
    • PBM screening applies the 50 MME-per-day and day-supply limits.
    Prior Authorization

    Medical Reviewer Review Required

    A Medical Reviewer must review requests for immediate-release opioids or prescriptions exceeding applicable MME or day-supply limits. Review is also required for extended-release opioids, methadone for pain, concentrated oral dosage forms, fentanyl products, formulary quantity-limit exceptions, and non-formulary opioids.

    • Immediate-release opioid requests exceeding 50 MME per day or the applicable day-supply limit require Medical Reviewer review.
    • Opioid-naive members may not receive more than 50 MME per day or the applicable seven-day adult or three-day under-18 supply limit.

    Policy Purpose and Scope

    This policy supports clinically appropriate opioid access while addressing dose, duration, monitoring, diversion, and patient-safety risks. It incorporates Maryland controlled-substance requirements and SUPPORT Act standards, including limits for opioid-naive patients and enhanced review for higher-risk formulations or regimens.

    Key Definitions

    Opioid naive
    DefinitionA member who has not been dispensed any opioid prescription
    Benefit used for definitionThe pharmacy benefit
    Lookback periodDuring the previous 30 days
    Medical Reviewer
    DefinitionA Medical Director or Health Plan Pharmacist
    Qualified roleMedical Director
    Qualified roleHealth Plan Pharmacist
    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyOpioid Prescription Prior Authorization
    Policy CodePolicy N/A
    Change TypeMaterial revision
    Effective Date07/2025
    Next Review DateN/A
    Key ActionSubmit medical records and a completed opioid prior authorization form for every opioid authorization request.
    SourceLink
    On This Page
    Opioid Coverage CriteriaInitial TherapyContinuation and Established TherapyQuantity and Dose LimitsDose, Supply, and Monitoring ParametersSubmission, Review, and Denial RisksPolicy Purpose and ScopeKey Definitions
  1. The request is for an extended-release opioid, including buprenorphine products indicated for chronic pain treatment. Extended-release opioids are reserved for patients on an established opioid regimen confirmed by prescription claims history or clinical documentation.
  2. The request is for methadone for pain.
  3. The request is for a concentrated oral dosage form.
  4. The request is for any fentanyl dosage form.
  5. The request exceeds formulary quantity limits (QL).
  6. The request is for a non-formulary opioid.
    • The member is opioid naive.
    • The ordered opioid prescription is for no more than 50 MME per day.<= 50 MME/day

    • Cumulative supply limit

      • The ordered prescription is for no more than a cumulative seven-day supply for an adult member.<= 7 days
      • The ordered prescription is for no more than a cumulative three-day supply for a member under 18 years of age.<= 3 days
    The prescriber has provided or offered a prescription for naloxone to the patient or the patient's household.
  7. A signed patient-prescriber contract is complete and included in the medical record.
  8. The pain management agreement has been renewed or updated within the last year.within the last 12 months

    9. Exceptions to urine drug screening and signed contract requirements

    • Post-discharge short-term therapy

      • The prescription follows discharge from a hospital, emergency department, or ambulatory surgery center.
      • The total anticipated therapy duration is no more than a 30-day medication supply.<= 30 days
    • The patient meets the applicable exemption from the signed patient-prescriber contract requirement for the same post-discharge short-term therapy circumstances.
    If urine drug screen documentation indicates that the patient may not be taking the medication as prescribed, MedStar Family Choice reserves the right to deny the request as not medically necessary.
    Supply for members under age 18
    Maximum supplyNo more than a three-day supply
    Member groupMembers under 18 years of age
    Review implicationRequests exceeding three days require Medical Reviewer review
    Formulary quantity limits
    Quantity standardFormulary quantity limits apply to opioid medications
    Exception reviewRequests exceeding formulary quantity limits require Medical Reviewer review
    Additional review categoryAll non-formulary opioids require Medical Reviewer review
    Supply for members under age 18
    Standard maximum≤ 3 days
    Applies toMembers under 18 years of age
    Above limitRequests exceeding the three-day supply limit require Medical Reviewer review
    Urine drug screening
    Minimum frequencyAt least annually
    Screening typeRandom urine drug screen
    Prescriber requirementThe prescriber must attest that the patient has or will have the required screening
    Pain management agreement update
    Required recencyWithin the last 1 year
    DocumentSigned patient-prescriber pain management agreement
    Record requirementThe agreement must be complete and included in the medical record
    Documentation Required

    Document Established Therapy for Extended-Release Opioids

    Extended-release opioids are reserved for members on an established opioid regimen. Submit prescription claims history or clinical documentation confirming established therapy.

    • Medical Reviewer review is required for all extended-release opioids, including buprenorphine products indicated for chronic pain.
    • Methadone for pain, concentrated oral dosage forms, and all fentanyl dosage forms also require Medical Reviewer review.

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