CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Long-Acting Opioid Prior Authorization Policy

Prior authorization policy for long-acting opioid analgesics for Neighborhood Health Plan of Rhode Island members, defining required medical information, initial (new start) criteria, renewal criteria, quantity/MME limits, non-formulary requirements, and specific product/day limits. Applies to chronic, around-the-clock opioid therapy and includes attestations and documentation requirements.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLong-Acting Opioid Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2019

Next Review DateJul 1, 2025

Key ActionProviders must obtain authorization; approvals are granted for 1 year and documentation is required for dosages over post quantity limits.

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief.

1Approval Duration

>=50Reassess Threshold (MME)

>=90Justification Required (MME)

>=200High OD Risk (MME)

Coverage Summary

Required Medical Information / Prescriber Attestations

Required Medical Information

ALL of the following

The prescriber attests that Rhode Island's regulations for Pain Management, Opioid Use and the Registration of Distributors of Controlled Substances are being followed.
The prescriber attests that they will use or are using an objective tool to monitor the member's pain.
The prescriber attests and acknowledges that the risk of serious harm is markedly increased with concurrent use of benzodiazepines (BZD) and other Central Nervous System (CNS) depressants.
The prescriber attests that the patient has a prescription for or is in possession of naloxone.
The prescriber attests that they have counseled the patient (and patient cohabitants, if available) on how to obtain and administer naloxone.
The prescriber attests to understanding the findings of the CDC's Clinical Practice Guideline for Prescribing Opioids for Pain (2022), including that long term opioid therapy is associated with increased risk for serious harm (opioid use disorder, overdose, and death); risk of harm increases with dosage; opioids pose risk to all patients and currently available tools cannot rule out risk for opioid use disorder or other serious harm; and evidence for clinical benefit of long term opioid therapy is insufficient.
The patient has tried and failed the following alternatives for the treatment of pain: non-pharmacologic therapy; non-opioid therapy; or non-pharmacologic therapy and/or non-opioid therapy in combination with a low dose opioid.
Members who have opioids prescribed for pain associated with a cancer diagnosis, terminal condition, sickle cell disease or pain being managed through hospice or palliative care shall have access to the medication.

Documentation Required

Prescriber attestations and counseling

Prescriber attests required at initiation and renewal per RI regulations and policy: use of objective pain monitoring, acknowledgement of increased risk with benzodiazepines/CNS depressants, naloxone possession and counseling (patient and cohabitants if available), understanding of CDC opioid prescribing guideline risks, and documentation of trials of alternatives (non‑pharmacologic, non‑opioid, or combination with low‑dose opioid).

Document at renewal: pain and function reassessment every 3 months to ensure clinically meaningful improvement outweighs safety risks.
Document at renewal: evidence that original opioid dosing has been titrated down from the initial authorization OR a clear clinical justification for not reducing dose.
Keep records of naloxone prescription/possession and counseling provided (including cohabitants when applicable).

Quantity Limits / MME Over-Threshold Criteria

Billing Rule

Enter daily dose on authorization

Enter the daily dose (number of tablets, capsules, or milliliters per day) on the authorization request. The policy limit is 200 MME/day or the FDA maximum dose, whichever is less. Providers requesting dosages above the posted quantity limits must provide documentation supporting medical necessity.

>= 50 MME/day — indicates need to reassess
>= 90 MME/day — requires justification
>= 200 MME/day — associated with overdose death (high OD risk)

Per the policy the prescriber must attest to understanding and following CDC opioid prescribing guidance (CDC Clinical Practice Guideline for Prescribing Opioids for Pain, 2022, and prior CDC guidelines). The policy highlights dose-dependent risk thresholds: ≥50 MME indicates need to reassess; ≥90 MME requires justification; and ≥200 MME is associated with overdose death. The policy defines chronic pain as generally lasting greater than 3 months.

Clinical Evidence & Background

The policy emphasizes adherence to Rhode Island regulations for pain management and opioid use, requires prescriber attestations including use of an objective pain-monitoring tool, naloxone possession/prescription and counseling, and understanding of CDC guidance (CDC Clinical Practice Guideline for Prescribing Opioids for Pain, 2022). It requires documentation of trials and failures of non-pharmacologic and non-opioid therapies (or appropriate justification) prior to authorization for long-term opioid therapy, and specifies that approvals are for one year with ongoing reassessment every 3 months at renewal.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLong-Acting Opioid Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2019

Next Review DateJul 1, 2025

Key ActionProviders must obtain authorization; approvals are granted for 1 year and documentation is required for dosages over post quantity limits.

On This Page

OpenPayer

Long-Acting Opioid Prior Authorization Policy

Coverage Summary

Required Medical Information / Prescriber Attestations

Initial Therapy (New Starts) Criteria

Continuation / Renewal Criteria

Quantity Limits / MME Over-Threshold Criteria

Applicable Codes and Product Quantity/MME Limits

Clinical Evidence & Background

Definitions

Revision History