CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Short-Acting Opioid Prior Authorization for high-dose short-acting opioids

A prior authorization form and requirements for covering short-acting opioid prescriptions at or above 90 morphine milligram equivalents (MME) per day for Neighborhood Health Plan of Rhode Island members; intended for prescribing clinicians and pharmacy staff completing authorization requests.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyShort-Acting Opioid Prior Authorization for high-dose short-acting opioids

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Short-Acting Opioid Prior Authorization Form for daily doses ≥90 MME to the fax number provided or use CoverMyMeds.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=90MME threshold for this form

30/20Opioid-naïve limit

50CDC reassess threshold

>=90Requires justification

Coverage Criteria

Authorization criteria for >=90 MME/day

Covered when ALL of the following are met for requests of short-acting opioids at or above 90 MME/day:

Primary indication and documentation: Requested drug is for pain associated with a cancer diagnosis, terminal condition, hospice, or palliative care OR for non-cancer pain with required documentation

If cancer/terminal/hospice/palliative and drug is formulary, no further questions unless non-formulary

Opioid-naive status and state limits: If patient is opioid-naïve, state law limits to <=30 MME/day and <=20 tablets; requests exceeding this for opioid-naïve patients trigger additional scrutiny or denial<=30 MME/day and <=20 tablets

See state opioid-naïve rule

CDC risk acknowledgement and risk mitigation: Prescriber attests to understanding CDC opioid prescribing guidance (>=50 MME/day indicates need to reassess; >=90 MME/day requires justification; >=200 MME/day associated with overdose), acknowledges increased risk with concurrent benzodiazepines/CNS depressants, has prescribed or patient has naloxone, and has counseled patient and cohabitant(s) on naloxone

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyShort-Acting Opioid Prior Authorization for high-dose short-acting opioids

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Short-Acting Opioid Prior Authorization Form for daily doses ≥90 MME to the fax number provided or use CoverMyMeds.

SourceLink

On This Page

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Provider Actions & Requirements

Prior Authorization

Prior authorization for ≥90 MME/day

Prior authorization required for daily opioid doses ≥ 90 MME/day. Use the Short-Acting Opioid Prior Authorization Form (for daily doses of 90 MMEs or greater). Fax the completed form to Neighborhood Health Plan of Rhode Island Pharmacy Department at 1-866-423-0945 or use Cover My Meds for real-time decisions.

Form title: Short-Acting Opioid Prior Authorization Form (For daily doses of 90 MMEs or greater)
Fax: 1-866-423-0945; Pharmacy Dept Phone: 401-427-8200
Cover My Meds: https://www.covermymeds.com/epa/caremark/

Step Therapy

Non-formulary trial requirement

Non-formulary drug requests require documentation of trial and failure of two formulary alternatives, or a clinical rationale why formulary alternatives are not appropriate.

Provide drugs tried and failed OR clinical rationale on the prior authorization form
If non-formulary and cancer/terminal/hospice exception applies, non-formulary rule still applies

Denial Risk

State opioid-naïve limit

Requests that exceed state opioid-naïve limits will not meet the opioid-naïve exception. The State of Rhode Island limits opioid-naïve patients to ≤ 30 MME/day and a maximum of 20 tablets.

If patient is opioid-naïve, do not exceed 30 MME/day or 20 total tablets per Rhode Island law
If request exceeds these limits, opioid-naïve exception is not applicable

Documentation Required

Required form fields

Required form fields: complete enrollee demographics, medication details, diagnosis, dates of therapy initiation, expected length of therapy, quantity, height/weight, drug allergies, and prescriber information including name, NPI, address, office phone, fax, signature, and date.

Enrollee: name, date of birth, address, city, state, zip, phone, member ID
Medication: name, strength/route, frequency, new prescription or date therapy initiated, expected length of therapy, quantity
Clinical: diagnosis, height/weight, drug allergies
Prescriber: name, NPI, address, office phone, fax, signature, date

Documentation Required

Clinical justification and prior therapy documentation

Clinical justification and prior therapy documentation must be provided for initial and continuation requests. For continuation requests, document prior dosing history (including any initial titration and reasons why dose reduction is inappropriate).

Document if therapy is for cancer, terminal condition, hospice, or palliative care
Indicate whether patient is opioid-naïve
State if request is >30 MME/day or >20 tablets and provide justification if applicable
For continuation: note original authorization dosing, any titration down, or rationale for maintaining dose

Documentation Required

Risk counseling and naloxone documentation

Risk counseling and naloxone documentation: prescriber must attest awareness of CDC opioid prescribing risks and thresholds, counsel the patient (and available cohabitants) on naloxone, and confirm the patient has a prescription for or possession of naloxone. Prescriber must acknowledge increased risks with concurrent benzodiazepines/CNS depressants.

Prescriber attestation to CDC guideline findings (risk increases ≥50 MME/day; significant risk ≥90 MME/day; overdose risk ≥200 MME/day)
Confirm counseling on naloxone and how to obtain/administer it
Confirm patient has a prescription for or possesses naloxone
Acknowledge risks with concurrent benzodiazepine or CNS depressant use

Documentation Required

Conservative treatment requirement

Conservative treatment requirement: document trial and failure of non-pharmacologic therapies and/or non-opioid therapies (in combination with a low-dose opioid when applicable). For opioid-naïve patients, document trial and failure of both non-pharmacologic and non-opioid therapies prior to higher-dose opioid requests.

Document non-pharmacologic therapies tried (e.g., physical therapy, cognitive behavioral therapy)
Document non-opioid pharmacologic therapies tried (e.g., NSAIDs, acetaminophen, adjuvant agents)
For opioid-naïve patients, both non-pharmacologic and non-opioid therapy trials are required before escalating opioid dosing

OpenPayer

Short-Acting Opioid Prior Authorization for high-dose short-acting opioids

Coverage Criteria

Coding & Thresholds

Provider Actions & Requirements

Conservative Treatment Requirements

Background