CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Short-Acting Opioid Post Limit Policy

Defines quantity limits, prior authorization requirements, and renewal criteria for short-acting opioid prescriptions for Neighborhood Health Plan of Rhode Island members; applies to prescribers and pharmacy claims processing for members in Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyShort-Acting Opioid Post Limit Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2019

Next Review DateJul 1, 2020

Key ActionObtain prior authorization when requested daily opioid doses exceed post-limit quantity limits; approvals issued for up to 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200maximum default daily MME limit

30opioid-naïve max MME/day

20opioid-naïve max tablets

1 yrauthorization duration

26 daysfill period duration

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Coverage and Authorization Criteria

Authorization criteria for doses above post limits

Covered when ALL of the following are met

Primary coverage criteria: 1) Member exceptions: patient with cancer, terminal condition, sickle cell disease, hospice or palliative care shall have access to medication (no restriction exceptions).

Per policy, these members are not subject to the post-limit restrictions.

Opioid-naïve limit: 2) For opioid-naïve members, total daily dosing must not exceed 30 MME/day and total quantity must not exceed 20 tablets per Rhode Island law.<= 30 MME/day; <= 20 tablets total

State prescribing limits apply to opioid-naïve members.

Conservative therapy requirement: 3) The patient has tried and failed nonpharmacologic therapy and non-opioid therapy, AND has tried nonpharmacologic therapy and/or non-opioid therapy in combination with a low-dose opioid.

Required prior to approval for dosing above post limits.

Prescriber attestations - guideline awareness: 4) The prescriber attests to understanding the CDC opioid prescribing guidance and acknowledges dose-related risks (≥ 50 MME increases risk and indicates reassessment; ≥ 90 MME sharply increases risk and requires justification; ≥ 200 MME associated with overdose death).see node text

Attestation required for authorization above post limits.

Prescriber attestations - concomitant medications: 5) The prescriber attests awareness that concurrent benzodiazepines and other CNS depressants markedly increase risk of serious harm.

Attestation required.

Naloxone: 6) The prescriber attests that the patient has a prescription for or is in possession of naloxone and that counseling on naloxone use (including cohabitants where available) has been provided.

Attestation and counseling required.

Non-formulary requirement: 7) For non-formulary opioid requests, the patient has tried and failed two formulary alternatives, or formulary alternatives are not appropriate (contraindication, adverse effect, etc.).

Documentation required for non-formulary agents.

Renewal criteria

Renewal covered when ANY of the following applies

Renewal: The original opioid dosing has been titrated down from the initial authorization OR, in the prescriber's clinical opinion, it is inappropriate to decrease the dose for this member.

Used to justify continuation at previously authorized dosing.

Members with pain related to a cancer diagnosis, a terminal condition, sickle cell disease, or who are receiving hospice or palliative care are excluded from these post-limit restrictions and shall have access to prescribed opioid therapy per the policy statement.

Requests that exceed a product's initial quantity limit will be rejected. Claims will also reject when quantities exceed 90 MME/day or the specified limits for concomitant analgesics — 4 g/day for acetaminophen or aspirin and 3200 mg/day for ibuprofen. When a request surpasses the initial quantity limit the claim will return a message indicating that quantity limits are exceeded.

For post-limit authorization entries, the policy uses a default daily ceiling of 200 MME/day (or FDA maximum dose, whichever is less) and per-product authorization limits are specified in the quantity limits chart; approvals above 200 MME/day are based on clinical judgment.

Product Limits, MME, and Code Lists

Opioid products with per-product authorization limits (examples)NDC|mixedCovered

APAP/codeine soln 120-12 mg/5 mL	Authorization Limit = 165 mL (60 MME/day)
APAP/codeine susp 120-12 mg/5 mL	Authorization Limit = 165 mL (60 MME/day)
APAP/codeine tab 300/15 mg	Authorization Limit = 13 tabs (30 MME/day)
Hydrocodone/APAP tab 5/325 mg	Authorization Limit = 12 tabs (60 MME/day)
Hydromorphone tab 4 mg	Authorization Limit = 9 tabs (180 MME/day)
Oxycodone tab 10 mg	Authorization Limit = 9 tabs (135 MME/day)
Oxycodone tab 30 mg	Authorization Limit = 4 tabs (180 MME/day)
Tapentadol tab 100 mg	Authorization Limit = 5 tabs (200 MME/day)
Tramadol 50 mg	Authorization Limit = 8 tabs (80 MME/day)

inv-06: Daily MME limit — 200 MME/day (default post limit) and related limit notes

Default post limit200 MME/day (default post limit) — approvals above 200 MME/day are based on clinical judgment.

Rejection triggersClaims will reject if quantities also exceed the initial quantity limit, 90 MME/day, 4 g/day acetaminophen or aspirin, or 3200 mg/day ibuprofen.

Entry on authorizationDaily Dose to enter on the authorization: 200 MME/day, 4 g acetaminophen or aspirin, 3200 mg ibuprofen, or FDA max dose (whichever is less).

Example product limitOxycodone 30 mg: 4 tablets/day = 180 MME/day (illustrates per-product calculation under the 200 MME/day post limit).

Prescriber Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required for Doses Above Post Limits

Prior authorization is required when requested daily doses exceed the plan Post Limit quantity limits. Providers seeking dosages over the Post Quantity Limits must provide Neighborhood with documentation explaining why the higher dosage is necessary. Approvals above 200 MME/day are based on clinical judgment; however requests that exceed the initial quantity limits (including 90 MME/day, 4 g/day acetaminophen or aspirin, or 3200 mg/day ibuprofen) will trigger a claim rejection unless prior authorization is obtained.

Applies when requested daily dose > Post Limit QL (see Opioid Analgesics Quantity Limits Chart).
Approvals above 200 MME/day considered on clinical judgment with documented justification.
If quantities exceed initial quantity limits (recommended product dose, 90 MME/day, 4 g/day acetaminophen/aspirin, 3200 mg/day ibuprofen) claims will reject.

Denial Risk

Quantity-limit Rejection Triggers

Claims will reject at point-of-sale if the quantity entered exceeds the product's initial quantity limit or specified safety thresholds (90 MME/day, 4 g/day acetaminophen or aspirin, 3200 mg/day ibuprofen). The policy uses daily-dose edits and a 26-day duration to represent a 30-day fill window for processing.

Quantity-limit rejections display messages indicating limits are exceeded.
Limits are enforced as daily dose edits; 26-day duration used to model a 30-day fill period.

Documentation Required

Non‑Formulary Documentation and Trials Required

For non-formulary agents, the prescriber must document that the patient has tried and failed two formulary alternatives, or that formulary alternatives are inappropriate (e.g., contraindication or adverse effect). Providers requesting dosages beyond Post Limits must supply Neighborhood with supporting documentation for why those dosages are necessary.

Non-formulary requests: documentation of trial of 2 formulary alternatives or reason formulary alternatives are not appropriate.
All requests for doses over Post Limits require supporting clinical documentation.

Documentation Required

Prescriber Attestations Required

Prescriber attestations must be included with requests for opioid therapy and for prior authorization when applicable. The prescriber must attest that they understand CDC guidance on opioid prescribing risk (including dose‑dependent increased risk at ≥50 MME and markedly increased risk with concurrent benzodiazepines/CNS depressants), that the patient has or has been prescribed naloxone, and that counseling on naloxone use has been provided to the patient (and cohabitants, if available).

Attest understanding of CDC Guideline findings (2016/2017) and 2022 CDC Clinical Practice Guideline regarding dose‑dependent harms (noting thresholds ≥50 MME, ≥90 MME, ≥200 MME).
Attest acknowledgement of increased risk with concurrent benzodiazepines/CNS depressants.
Attest patient has a prescription for or possession of naloxone and that naloxone counseling was provided.

Key Terms and Abbreviations

inv-12: MME — Morphine milligram equivalents; basis for daily dose limits and safety thresholds

DefinitionMorphine milligram equivalents (MME): used as the basis for daily dose limits and safety thresholds referenced throughout the policy.

Risk thresholds referencedPolicy references dose-related risk: ≥50 MME (significant increased risk — reassess), ≥90 MME (sharp increase — requires justification), ≥200 MME (associated with overdose death).

Use in limitsMME is used to set daily dose edits and per-product authorization limits (authorization limits are expressed in MME/day and product-specific tablet/volume limits).

inv-13: Opioid-naïve member — Rhode Island state limits: max 30 MME/day and up to 20 tablets total for opioid-naïve members

State opioid‑naïve daily limitOpioid‑naïve members shall not exceed 30 MME total daily dose per day per Rhode Island law.

Maximum tablets for opioid‑naïveMaximum total of 20 tablets for opioid‑naïve members per Rhode Island law.

Context of definitionApplies to members who are newly prescribed opioids (opioid‑naïve) as referenced in the Required Medical Information section of the policy.

OpenPayer

Short-Acting Opioid Post Limit Policy

Coverage and Authorization Criteria

Product Limits, MME, and Code Lists

Prescriber Requirements and Prior Authorization

Step Therapy Before Dose Escalation

Key Terms and Abbreviations

Clinical Rationale and References