CurrentMedStar Family Choice MarylandPolicy 218

Opioid Prescription Prior Authorization

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This policy governs MedStar Family Choice Maryland’s evaluation and authorization of opioid prescriptions for Medicaid managed care members. It establishes automated and Medical Reviewer requirements, documentation and safety attestations, exceptions, denial conditions, and limits for opioid therapy.

Policy Summary

PayerMedStar Family Choice Maryland

PolicyOpioid Prescription Prior Authorization

Policy CodePolicy 218

Change TypeUpdated and clarified

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit a completed opioid prior authorization form with supporting medical records for every opioid prior authorization request.

SourceLink

POLICY UPDATE CHANGES

The July 2026 revision updated managed care standards and regulatory references to current references.

The policy clarified the review requirements for opioid prescriptions, including extended-release opioids, buprenorphine products for chronic pain, methadone for pain, concentrated oral dosage forms, fentanyl, quantity-limit overrides, and non-formulary opioids.

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

The policy added or clarified documentation and safety requirements involving PDMP review, annual random urine drug screening, naloxone, and a current pain-management agreement.

The policy added an exception for sickle cell disease that does not apply when the member has received gene therapy.

All opioidsPrescriptions requiring prior authorization

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CurrentMedStar Family Choice MarylandPolicy 218

Opioid Prescription Prior Authorization

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Policy Summary

PayerMedStar Family Choice Maryland

PolicyOpioid Prescription Prior Authorization

Policy CodePolicy 218

Change TypeUpdated and clarified

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit a completed opioid prior authorization form with supporting medical records for every opioid prior authorization request.

SourceLink

POLICY UPDATE CHANGES

The July 2026 revision updated managed care standards and regulatory references to current references.

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

The policy added or clarified documentation and safety requirements involving PDMP review, annual random urine drug screening, naloxone, and a current pain-management agreement.

The policy added an exception for sickle cell disease that does not apply when the member has received gene therapy.

All opioidsPrescriptions requiring prior authorization

50 MME/dayAutomated opioid dose threshold

7 daysMaximum automated supply for adults

3 daysMaximum automated supply under 18

30 daysDischarge exception supply

24 hoursDecision timeframe

Coverage Criteria

Automated Authorization Parameters

Automated authorization applies when all of the following are met:

Automated opioid parameters: The opioid prescription is no more than 50 MME per day and does not exceed the applicable supply limit.≤50 MME/day; ≤7 days for adults or ≤3 days for members under 18

Requests exceeding these parameters require Medical Reviewer review.

Population Exemptions

The following members are exempt from opioid prior authorization requirements:

Exempt populations: The member is undergoing active cancer treatment; has sickle cell disease and has not received gene therapy; is receiving hospice care; is receiving palliative care; or resides in a long-term care or skilled nursing facility.

The sickle-cell exception does not apply after gene therapy, including Casgevy, Lyfgenia, or similar therapy.

Opioid-Naive Exception

An opioid-naive member is exempt when all of the following are met:

Opioid-naive short course: The member is opioid naive, the prescription is no more than 50 MME per day, and the cumulative supply does not exceed the applicable duration limit.≤50 MME/day; ≤7 cumulative days for adults or ≤3 cumulative days for members under 18

Opioid naive means no opioid dispensing through the pharmacy benefit during the previous 30 days.

Extended-Release Opioid Therapy

Extended-release opioid coverage requires all of the following:

Established opioid regimen: The requested product is an extended-release opioid and the patient is on an established opioid regimen confirmed by prescription claims history or clinical documentation.Established regimen confirmed by claims history or clinical documentation

All extended-release opioids require Medical Reviewer review, including buprenorphine products indicated for chronic pain.

Discharge-Related Documentation Exception

The urine-screening and treatment-agreement requirements do not apply when all of the following are met:

Short-term discharge exception: The prescription follows discharge from a hospital, emergency department, or ambulatory surgery center and the total anticipated therapy duration is no more than a 30-day supply.≤30-day supply

This exception applies to both the random urine drug screen and the signed patient-provider pain-management or opioid-treatment agreement.

The sickle-cell disease exemption from opioid prior authorization applies only when the patient has not received gene therapy. The exemption does not apply after treatment with gene therapies such as Casgevy (exagamglogene autotemcel), Lyfgenia (lovotibeglogene), or similar therapies.

Opioid prior authorizations requested by out-of-network outpatient physicians are not covered. A Medical Reviewer may grant a one-time supply of up to 30 days when a continuity relationship between the member and prescriber can be established, allowing time to transition future services and prescriptions to an in-network provider. Members may be referred to a Care Manager to assist with establishing in-network care.

A request may be considered not medically necessary when urine drug screen documentation indicates that the patient may not be taking the medication as prescribed. The prescriber must attest to a random urine drug screen at least annually unless the prescription follows discharge from a hospital, emergency department, or ambulatory surgery center and the anticipated therapy does not exceed a 30-day supply.

Authorization Parameters

Morphine milligram equivalent dose

Daily MME limitNo more than 50 MME per day

Automated screeningThe PBM screens opioid requests at or below 50 MME per day

Medical Reviewer reviewRequests exceeding 50 MME per day require Medical Reviewer review

Adult supply duration

Adult maximumNo more than a seven-day supply

Automated screeningThe PBM screens adult opioid requests against the seven-day supply limit

Medical Reviewer reviewAdult requests exceeding a seven-day supply require Medical Reviewer review

Provider Requirements and Review Triggers

Prior Authorization

Universal Opioid Prior Authorization

Prior authorization is required for all opioid medications. The Pharmacy Benefits Manager (PBM) automatically screens requests for SUPPORT Act minimum standards before additional review.

≤ 50 morphine milligram equivalents (MME) per day.
Maximum seven-day supply for adults.
Maximum three-day supply for members under 18 years of age.

Prior Authorization

High-Dose or Extended-Duration Immediate-Release Therapy

A Medical Reviewer must review immediate-release opioid prescriptions or combinations that exceed the applicable dose or duration limits.

More than 50 MME per day.
More than a seven-day supply for adults.
More than a three-day supply for members under 18 years of age.
Opioid-naïve members may not be dispensed beyond the applicable limits for members under 18 years of age.

Policy Background

This policy is intended to support clinically appropriate access to opioid medications while monitoring utilization and promoting patient safety. It applies dose and duration limits, prescription-history and formulation review, and required safety documentation, including review of the controlled-substance PDMP, annual random urine drug screening, naloxone provision or offer, and a current pain-management agreement. Specified populations and qualifying short-term post-discharge prescriptions are exempt from applicable requirements.

Definitions

Opioid naïve

DefinitionA member who has not been dispensed any opioid prescription through the pharmacy benefit during the previous 30 days

Lookback periodPrevious 30 days

Relevant benefitPharmacy benefit

Medical Reviewer

DefinitionA Medical Director or Health Plan Pharmacist

Medical DirectorA Medical Director may serve as the Medical Reviewer

Health Plan PharmacistA Health Plan Pharmacist may serve as the Medical Reviewer

Initial Opioid Authorization

Initial opioid authorization is subject to all applicable dose, duration, documentation, and safety requirements:

Initial opioid authorization: The request is submitted with a completed opioid prior authorization form and supporting medical records, meets the applicable dose and duration rules or receives Medical Reviewer review, and includes required safety attestations unless an applicable exception applies.≤50 MME/day and ≤7 days for adults or ≤3 days for members under 18 for automated screening

All opioids require prior authorization. Required attestations include PDMP review, annual random urine drug screening, naloxone provision or offer, and a current signed patient-prescriber pain-management or opioid-treatment agreement, unless the discharge-related exception applies.

Continuation and Maintenance Therapy

Established Extended-Release Opioid Regimen

Continuation or maintenance therapy with extended-release opioids requires:

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

This requirement applies to extended-release opioids, including buprenorphine products indicated for chronic pain. Medical Reviewer review is required.

Opioid Quantity Limits

All opioids

Daily limitNo more than 50 MME per day

Applies toAll opioids

Requests above limitRequests exceeding 50 MME per day require Medical Reviewer review

Opioids for adults

Maximum durationNo more than a seven-day supply

Applies toOpioids for adults

Requests above limitRequests exceeding a seven-day supply require Medical Reviewer review

Policy Summary

PayerMedStar Family Choice Maryland

PolicyOpioid Prescription Prior Authorization

Policy CodePolicy 218

Change TypeUpdated and clarified

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit a completed opioid prior authorization form with supporting medical records for every opioid prior authorization request.

SourceLink

On This Page

Supply duration for members under 18

Maximum durationNo more than a three-day supply

Applicable membersMembers under 18 years of age

Medical Reviewer reviewRequests exceeding a three-day supply require Medical Reviewer review

Urine drug screening

Required frequencyAt least annually

Prescriber attestationThe prescriber must attest that the patient has or will have a random urine drug screen

Discharge exceptionThe requirement does not apply to qualifying prescriptions following discharge from a hospital, emergency department, or ambulatory surgery center when anticipated therapy is no more than 30 days

Pain-management agreement validity

Renewal timeframeRenewed or updated within the last one year

Required documentationA signed contract between the patient and prescriber must be complete and included in the medical record

Discharge exceptionThe contract requirement does not apply to qualifying prescriptions following discharge when anticipated therapy is no more than 30 days

Discharge-related therapy exception

Maximum supplyNo more than a 30-day medication supply

Qualifying settingsDischarge from a hospital, emergency department, or ambulatory surgery center

Requirements exceptedThe urine drug screening and signed patient-provider contract requirements do not apply when the discharge criteria are met

Prior Authorization

Specialty Opioid Products

Extended-release opioids are reserved for members with an established opioid regimen confirmed by prescription claims history or clinical documentation. Medical Reviewer review is required for the following products and situations.

All extended-release opioids, including buprenorphine products indicated for chronic pain.
Methadone for pain.
Concentrated oral dosage forms.
All fentanyl dosage forms.

Prior Authorization

Quantity-Limit and Non-Formulary Requests

Medical Reviewer review is required for opioid requests that exceed formulary quantity limits or involve a non-formulary opioid.

Requests exceeding formulary quantity limits (QL).
All non-formulary opioid requests.

Documentation Required

Submission and Decision Timeframe

Submit the completed opioid prior authorization materials to MedStar Family Choice. MFC must render a decision within 24 hours.

Fax completed forms to MFC Maryland at 1-888-243-1790 or 410-933-2274.
The 24-hour decision timeframe applies to the request evaluation process.

Documentation Required

Medical Records and PA Form

Every opioid review request must include supporting medical records and a completed Opioid Prior Authorization form. The form is available through the MedStar Family Choice provider website.

Medical records must support the request.
Use the MedStar Family Choice Opioid Prior Authorization form for every opioid PA request.
Incomplete forms or submissions without supporting clinical documentation may result in denial.

Documentation Required

PDMP Review Required

The prescriber must attest that the Controlled Substance Prescription Drug Management Program (PDMP) was reviewed in CRISP.

Document or attest to review of controlled-substance prescriptions in CRISP.

Documentation Required

Annual Random Urine Drug Screen

The prescriber must attest that the patient has had or will have a random urine drug screen at least annually.

The requirement is waived when the prescription follows discharge from a hospital, emergency department, or ambulatory surgery center and the anticipated therapy is no more than a 30-day supply.
If urine drug screen documentation suggests the patient may not be taking the medication as prescribed, the request may be denied as not medically necessary.

Documentation Required

Naloxone

The prescriber must provide or offer a naloxone prescription to the patient or the patient’s household.

Attest on the PA form that naloxone was provided or offered.

Documentation Required

Pain-Management Agreement

A signed pain-management or opioid-treatment agreement between the patient and prescriber must be completed and included in the medical record.

The agreement must be renewed or updated within the last year.
The agreement requirement is waived when the prescription follows discharge from a hospital, emergency department, or ambulatory surgery center and the anticipated therapy is no more than a 30-day supply.

Documentation Required

Medication-Specific Request Details

Submit a separate form for each medication request and provide the medication-specific information needed for review.

Medication name.
Strength.
Quantity.
SIG/directions.
Length of treatment in months.
The form identifies request types including quantity limit, high dose, long-acting opioid, non-preferred, methadone for pain, fentanyl, and other.

Denial Risk

Unresolved Clinical or Safety Concern

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.

Resolve all identified clinical and safety concerns before or during submission.

Denial Risk

Prescription Outside Usual Professional Treatment

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.

The concern includes prescriptions for an indication outside the prescriber’s scope, such as an oncologist prescribing opioids for pain unrelated to a cancer diagnosis.

Denial Risk

Indication Outside Prescriber Scope

A request may be denied when the opioid indication is outside the prescriber’s scope of practice or specialty.

Example: an oncologist prescribing opioids for pain that is not related to a cancer-related diagnosis.

Denial Risk

Incomplete Submission

Incomplete prior authorization forms or missing supporting clinical documentation may result in denial.

Include all required medical records.
Complete every applicable section of the Opioid Prior Authorization form.

Denial Risk

Urine Drug Screen Concern

MedStar Family Choice reserves the right to deny an opioid request as not medically necessary when urine drug screen documentation suggests the patient may not be taking the medication as prescribed.

Ensure screening documentation is complete and accurately reflects treatment adherence.

Billing Rule

Out-of-Network Outpatient Prescriber

Opioid prior authorizations requested by out-of-network 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 with the out-of-network prescriber can be established.
The exception is intended to allow time to transition to an in-network provider without a gap in care.
Refer the patient to a Care Manager to establish care with an in-network provider.

Billing Rule

Early Refill Restriction

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

Apply the early-refill requirements and exceptions in Pharmacy Policy 204.

Opioids for members under 18

Maximum durationNo more than a three-day supply

Applies toOpioids for members under 18 years of age

Requests above limitRequests exceeding a three-day supply require Medical Reviewer review