CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Opioid Prior Authorization Policy Acting

Defines prior authorization requirements, initial and renewal criteria, quantity/MME limits, non-formulary approval conditions, and a detailed per-product daily quantity/MME chart for opioid analgesics for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOpioid Prior Authorization Policy Acting

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2019

Next Review DateJul 1, 2025

Key ActionProviders seeking dosages over the post-quantity limits must provide documentation to Neighborhood explaining why such dosages are necessary.

POLICY UPDATE CHANGES

No material changes

200Maximum standard MME per day (limit is lesser of 200 MME/day or FDA max dose)

3 monthsRenewal reassessment interval

2Non-formulary trial requirement (number to fail)

Coverage Summary

This is the Neighborhood Health Plan of Rhode Island Opioid Prior Authorization policy. Its purpose is to define prior authorization requirements, quantity/MME limits, and clinical criteria to mitigate risks of opioid therapy including overdose and opioid use disorder, by requiring prescriber attestations, trials of alternatives, documentation for doses above limits, naloxone access/counseling, and periodic reassessment. Coverage stance: covered_with_criteria.

Required Medical Information & Criteria

Required Medical Information

Prescriber attestation requirements and general statements that must be met:

ALL of the following

Prescriber attestation: Prescriber attests that Rhode Island regulations for Pain Management; Opioid Use and the Registration of Distributors of Controlled Substances are followed.
Population access: Members with opioids prescribed for an associated cancer diagnosis, terminal condition, sickle cell disease, or managed through hospice or palliative care shall have access to the medication.
Pain monitoring: Prescriber attests they will use an objective tool to monitor the member's pain.
Naloxone possession: Prescriber attests the patient has a prescription for or is in possession of naloxone.
CNS depressant risk: Prescriber attests and acknowledges that the risk of serious harm is markedly increased with concurrent use of benzodiazepines and other CNS depressants.
Naloxone counseling: Prescriber attests they have counseled the patient (and cohabitants, if available) on how to obtain and administer naloxone.
CDC guideline understanding: Prescriber attests understanding of CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022) including that long-term opioid therapy is associated with increased risk for serious harm, risk increases with dosage, evidence for long-term benefit is insufficient, and current tools cannot fully rule out risk for opioid use disorder or other serious harm.
Failed non-opioid therapy: Prescriber attests the patient has tried and failed non-opioid therapy.
Failed non-pharmacologic therapy: Prescriber attests the patient has tried and failed non-pharmacologic therapy.
Combination therapy trial: Prescriber attests the patient has tried non-pharmacologic and/or non-opioid therapy in combination with a low-dose opioid.

New Starts / Initial Criteria

Criteria for initiation of chronic, around-the-clock opioid therapy:

ALL of the following

Non-opioid-naive requirement: Requested drug is prescribed for chronic, daily, around-the-clock long-term treatment in a patient who is not opioid-naive (patient has been taking an opioid).
Chronic definition: Chronic generally defined as pain that typically lasts greater than 3 months.

Renewal Criteria

Criteria required at renewal / continued authorization:

ALL of the following

Dose titration or justification: Original opioid dosing has been titrated down from the initial authorization or prescriber states it is inappropriate to decrease the dose for this member.
Reassessment interval: Patient will be reassessed every 3 months to ensure clinically meaningful improvement in pain and function outweighs risks to patient safety.

Quantity Limit / MME Considerations

Requirements when prescribing above MME thresholds and related attestations:

ALL of the following

CDC guidance attestation: Prescriber attests understanding of CDC guidance (2016/2017 and 2022) about dose-dependent increased risk (50 MME, 90 MME, 200 MME referenced) and need to reassess or justify dosages at higher MME levels.
Documentation for higher dosages: Providers seeking dosages over the post-quantity limits must provide Neighborhood with documentation as to why such dosages are necessary.
Non-formulary approval conditions: For non-formulary opioid approvals: patient has tried and failed 2 formulary alternatives, or formulary alternatives are not appropriate (contraindication, adverse effect, etc.).

Provider Actions & Requirements

Prior Authorization

Prior authorization required for opioids exceeding quantity/MME limits

Providers seeking dosages over the post-quantity limits must provide documentation to Neighborhood explaining why such dosages are necessary.

Documentation Required

Prescriber attestations required

Prescriber must attest to adherence to Rhode Island regulations, use of objective pain monitoring tools, naloxone possession/prescription and counseling, awareness of benzodiazepine/CNS depressant risks, prior trials of non-opioid/non-pharmacologic therapies, and understanding of the CDC Clinical Practice Guideline (2022).

Attest that Rhode Island Pain Management and Controlled Substances regulations are followed.
Attest they will use an objective tool to monitor the member's pain.
Attest the patient has a prescription for or is in possession of naloxone and that counseling (and cohabitant counseling, if available) was provided on obtaining/administering naloxone.
Attest awareness that concurrent benzodiazepines/CNS depressants markedly increase risk of serious harm.
Attest prior trial and failure of non-opioid and non-pharmacologic therapies (or combination with low‑dose opioid).
Attest understanding of the CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022) including dose-dependent risk and limited evidence of long-term benefit.

Documentation Required

Renewal reassessment

Patient must be reassessed every 3 months with documentation that improvement in pain and function outweighs safety risks.

Reassessment interval: every 3 months.
Document that clinically meaningful improvement in pain and function outweighs risks to patient safety.

Prior Authorization

Non-formulary opioid approvals

For non-formulary opioid approval, prescriber must document trial and failure of 2 formulary alternatives, or that formulary alternatives are not appropriate (contraindication, adverse effect, etc.).

Documented trial and failure of 2 formulary alternatives, or
Documented contraindication or adverse effect making formulary alternatives inappropriate.

Background & Evidence

Background: The policy aligns with CDC prescribing guidance (2016/2017 and 2022) and Rhode Island regulations for pain management to reduce risks of overdose and opioid use disorder. Goals include mitigating overdose and opioid use disorder by enforcing prescriber attestations, requiring trials of non-opioid and non‑pharmacologic alternatives, assuring naloxone prescription/possession and counseling, and conducting periodic reassessment of patients.

Mandatory elements include prescriber attestations to RI regulatory compliance and understanding of CDC guidance, documentation of trials of alternatives (including failure of 2 formulary alternatives for non-formulary approvals when applicable), confirmation of naloxone access and counseling, and reassessment at least every 3 months; providers must document justification for dosages above established quantity/MME limits (limit is the lesser of 200 MME/day or FDA maximum dose).

Evidence / Guidelines

Guidelines referencedCDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022); CDC Guideline (2016/2017)

Definitions

ChronicPain that typically lasts greater than 3 months.

MMEMorphine milligram equivalents per day.

Arymo ER 15 mg	4 tabs per day (60 MME/day)
Arymo ER 30 mg	4 tabs per day (120 MME/day)
Arymo ER 60 mg	3 tabs per day (180 MME/day)
Avinza 30 mg	2 caps per day (60 MME/day)
Avinza 45 mg	2 caps per day (90 MME/day)
Avinza 60 mg	2 caps per day (120 MME/day)
Avinza 75 mg	2 caps per day (150 MME/day)
Avinza 90 mg	2 caps per day (180 MME/day)
Avinza 120 mg	1 cap per day (120 MME/day)
Belbuca 75 mcg	3 films per day (6.75 MME/day)

OpenPayer

Opioid Prior Authorization Policy Acting

Coverage Summary

Required Medical Information & Criteria

Opioid Product Quantity Limits (per-product daily limits)

Provider Actions & Requirements

Background & Evidence

Revision History