CurrentNeighborhood Health Plan of Rhode IslandPolicy 2219-M

Opioids ER Step Therapy with MME Limit and Post Limit Prior Authorization

Defines step therapy, quantity limits, and post‑limit prior authorization criteria for extended‑release (ER) opioid analgesics for the payer's pharmacy program; affects prescribers and pharmacists submitting PA for listed ER opioid products.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOpioids ER Step Therapy with MME Limit and Post Limit Prior Authorization

Policy CodePolicy 2219-M

Change TypeNo material changes

Effective DateFeb 2, 2024

Next Review DateN/A

Key ActionObtain prior authorization when step therapy or quantity/MME thresholds are not met (e.g., no ≥8-day IR or ≥30-day ER prior use, or supply corresponds to ≥90 MME/day).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

<90 MME/dayno-auth threshold

<200 MME/dayauth-eligible threshold

severalinitial-zero strengths

30/90 daysupply durations

12 mopalliative DOA

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Coverage Criteria for Extended‑Release (ER) Opioid Analgesics

General coverage criteria for ER opioids

Coverage aligned with FDA indications and program step/limit requirements; covered when ALL of the following are met:

FDA indication and reserve use: Product is being used for management of severe, persistent pain requiring daily, around‑the‑clock opioid treatment and alternative options are ineffective, not tolerated, or inadequate

Multiple product-specific indications and limitations stated (not PRN)

Opioid tolerance for select products: For products labeled for opioid‑tolerant patients (e.g., fentanyl transdermal, hydromorphone ER), patient must be opioid tolerant defined as >=60 mg morphine/day or equianalgesic dose for >=1 week>=60 mg morphine/day

See product labeling for equivalent doses (e.g., fentanyl mcg/hr, oxycodone, hydromorphone, oxymorphone, hydrocodone)

Step therapy/PA compliance: Prescriber has met step therapy requirements or obtained prior authorization when initial limit or post‑limit criteria apply

Policy type: Initial Step Therapy/Initial Limit; Post Limit PA; see step therapy rules for IR/ER prior use requirements

Pain associated with cancer/sickle cell/terminal/hospice/palliative care

Coverage may be granted for specified pain conditions when requested drug is being prescribed for:

Special-condition coverage: Pain associated with cancer, sickle cell disease, a terminal condition, or pain managed through hospice or palliative care

Authorization may be granted for these indications

Chronic non-cancer pain

Coverage for chronic pain when ALL of the following are met:

Chronic pain authorization criteria: 1) Patient can safely take the requested dose based on opioid history (prescribe the lowest effective dose); 2) Pain will be reassessed in the first month after the initial prescription or any dose increase AND every 3 months thereafter; 3) Patient will be evaluated and monitored regularly for development of opioid use disorder; 4) Patient meets ONE of: has taken an immediate‑release opioid for at least one week OR request is continuation of ER therapy for a patient receiving ER opioid for at least 30 days; additionally, methadone requests must NOT be for detoxification or maintenance treatment of opioid addiction.

Authorization may be granted for chronic severe and persistent pain when all criteria met

Quantity limits and MME-based coverage tiers

Coverage and quantity limits are provided according to MME/day bands and supply durations; quantities accumulate across drugs sharing the same unit size.

Supply-duration and MME logic

Quantity table rows: Per‑drug and per‑strength quantity limits are specified in the quantity limits chart (examples include Belbuca, Butrans, fentanyl transdermal, hydrocodone ER, hydromorphone ER, methadone, morphine ER, OxyContin, etc.) with month and 3‑month unit counts tied to MME/day values.per table
See quantity limits chart for specific per‑product limits.

Quantity units accumulate: The quantity limits for drugs with the same unit size should accumulate across products (e.g., drugs with 30 units accumulate together, drugs with 60 units accumulate together).

Applies to enforcement of month and 3‑month limits

Quantity limits and post-limit rules

Coverage is governed by per-product and per-strength quantity limits and daily MME edits as listed below; some strengths are initially blocked (zero) and require post-limit prior authorization.

Per-product strength rules: Each ER opioid product and strength has specific quantity limits for 30‑day and 90‑day fills and an associated daily MME edit (examples include morphine ER, MS Contin, Nucynta ER, OxyContin, oxymorphone ER, tramadol ER, Xtampza ER, fentanyl transdermal, Belbuca, Butrans, hydrocodone ER, hydromorphone ER, methadone).see chart entries

Refer to quantity limits chart for per‑strength month and 3‑month counts and MME/day mappings

Initial-zero rule: For strengths marked with '***' or explicitly shown as initial limit = 0, the system limit is zero and coverage requires post‑limit prior authorization.initial limit = 0

Multiple chart entries indicate 0*** for initial block; requests for these strengths are considered only via post‑limit PA

Extended‑release (ER) opioid formulations are not indicated for as‑needed (PRN) use and should be reserved for patients for whom alternative treatments (non‑opioid analgesics or immediate‑release opioids) are ineffective, not tolerated, or otherwise inadequate. Multiple product labels (for example, Belbuca, Butrans, ConZip, fentanyl transdermal, hydromorphone ER, hydrocodone ER, methadone formulations) explicitly state they are not indicated as PRN analgesics and advise reserving ER agents for continuous, around‑the‑clock therapy when necessary.

Because ER opioids carry increased risks of addiction, misuse, overdose, and death relative to shorter‑acting formulations, prescribers should restrict ER opioid use to patients who meet the policy's coverage criteria (including step‑therapy and tolerance requirements) and document why non‑opioid or immediate‑release options are not appropriate for the patient.

Methadone requested for pain management is subject to the same ER opioid coverage rules, but methadone products intended for detoxification or maintenance treatment of opioid addiction are excluded from coverage under this ER opioid pathway. Federal regulations require methadone for addiction treatment to be dispensed through certified opioid treatment programs under 42 CFR; such uses are not processed through this ER opioid step‑therapy/PA pathway.

When a methadone product is requested for chronic pain, the prescriber must confirm the request is not for detoxification or maintenance of opioid/substance use disorder and must meet the chronic‑pain authorization requirements (including monitoring and documentation of opioid history) described in the policy.

Some product strengths are effectively excluded at initial claim adjudication because the system limit for those strengths is set to zero (initial limit = 0). Entries marked with the chart notation indicating an initial zero limit will not process at point‑of‑sale and will require a post‑limit prior authorization for any coverage consideration.

Providers should be aware that these initial‑zero strengths must be addressed via the post‑limit prior authorization workflow and that the policy explicitly requires clinical justification for such requests before coverage will be granted.

Use of ER opioid formulations when adequate pain control can be achieved with non‑opioid analgesics or immediate‑release (IR) opioids is considered outside the indicated use of ER products and may be judged not medically necessary. Multiple product labels and the policy limitations state ER opioids should be reserved for patients who require continuous, around‑the‑clock opioid therapy and for whom alternatives are inadequate.

Prescribers seeking ER opioid coverage must document the clinical rationale demonstrating why IR or non‑opioid options are insufficient and must meet the policy's step‑therapy and documentation requirements to avoid denial or requirement for prior authorization.

Key Definitions and MME Thresholds

Opioid tolerance threshold — definition

Opioid-tolerant definition>= 60 mg oral morphine per day or an equianalgesic dose (patient taking this dose for ≥1 week)

Equivalent examples in policy25 mcg/hr transdermal fentanyl; 30 mg oral oxycodone; 8 mg oral hydromorphone; 25 mg oral oxymorphone; 60 mg oral hydrocodone (per package inserts)

Documentation noteTolerance should be demonstrated for products labeled for opioid-tolerant patients (e.g., fentanyl transdermal, hydromorphone ER)

MME/day thresholds referenced

No-PA initial coverage threshold<90 MME/day when step therapy criteria are met

Authorization-eligible thresholdCoverage for supplies corresponding to <200 MME/day may be provided through prior authorization when coverage conditions are met

What Providers Must Do / Authorization & Documentation

Step Therapy

Step Therapy / Limit Prior Authorization

Step therapy applies to the ER opioid products listed; prescribers must try alternatives (non-opioid analgesics or immediate‑release opioids) first when appropriate. Initial step therapy/quantity limits apply unless the patient has prior opioid use history or qualifying diagnoses (see criteria).

Step Therapy: Applies to extended‑release opioid analgesics listed in the policy.
Reserve use: ER products (e.g., Belbuca, Butrans) should be reserved for patients for whom alternatives are ineffective, not tolerated, or inadequate.
Not for PRN use: Certain products (e.g., Belbuca, Butrans) are not indicated as as‑needed analgesics.

Prior Authorization

Claim Will Reject and Require Prior Authorization

If the patient does not have at least an 8‑day supply of an immediate‑release (IR) opioid or at least a 30‑day supply of an extended‑release (ER) opioid in the past 90 days, the claim will reject at point‑of‑sale with a message that prior authorization is required. Requests submitted after rejection will be evaluated under the authorization criteria.

Initial Therapy / Step Therapy Requirements

Initial therapy rules

Initial step therapy and limits apply as stated in the policy header.

Initial step/limit: Initial step therapy and initial quantity limits apply to the listed extended‑release opioid products; prior authorization is required if initial criteria are not met.

Policy type indicated as 'Initial Step Therapy/Initial Limit; Post Limit PA'

Initial therapy / Step therapy

Initial step therapy requirements and quantity limits for new starts:

Prior use prerequisite: 1) Patient must have at least an 8‑day supply of an immediate‑release (IR) opioid OR at least a 30‑day supply of an ER opioid within the past 90 days to bypass prior authorization; 2) If the prior‑use requirement is not met, the claim will reject and prior authorization is required and the PA authorization criteria will be applied.>=8 days IR OR >=30 days ER in past 90 days

Continuation and Palliative Care

Continuation therapy

Continuation of previously authorized ER opioid therapy:

Continuation criteria: Request is for continuation of therapy for a patient who has been receiving an ER opioid agent for at least 30 days (meets the step therapy exception).>=30 days ER use

Allows continuation without requiring prior IR use

Continuation / palliative care

Palliative care continuation note:

Palliative care duration: For palliative care, duration of authorization (DOA) is 12 months.12 months

Explicitly stated in policy notes

Step Therapy Tables and Requirements

Requirement	Coverage status
Step therapy required for extended‑release (ER) opioid analgesics listed in this policy; initial step therapy/initial limits apply
Post‑limit prior authorization applies when requested quantity exceeds the charted quantity limits (post‑month or post‑3‑month columns) or when initial system limit is zero for a drug/strength

Prior use requirement	Evidence required
Patient must have at least an 8‑day supply of an immediate‑release (IR) opioid in the past 90 days
OR patient must have been receiving an extended‑release (ER) opioid for at least 30 days (continuation) in the past 90 days

Coverage without prior authorization	Quantity-limit organization
Coverage without prior authorization is available when step therapy criteria are met for supplies corresponding to <90 MME/day
Quantity limits differ between initial period (Initial 1‑month and Initial 3‑month columns) and post‑limit period (Post Month and Post 3‑Month columns); post limits correspond to the higher <200 MME/day authorization band

Step	Description
Step 1
Prescriber must meet step therapy prerequisite: confirm prior IR use (≥8 days) or continuation on ER (≥30 days) for claim to process without PA; otherwise submit prior authorization
Step 2
Coverage without PA applies only for supply quantities corresponding to <90 MME/day when step therapy criteria are satisfied; quantities and unit counts are specified per drug/strength in the quantity limits chart (initial month and initial 3‑month columns)
Step 3
If the requested quantity exceeds the initial limits, post‑limit prior authorization is required; post limits correspond to quantities mapped to <200 MME/day (post‑month and post‑3‑month columns) or for strengths with an initial limit of zero

Product- and Strength-Specific Quantity Limits

Belbuca examples — initial and 3-month caps

Initial 1-month Belbuca example60 films/month (2 films/day) for initial 1-month <90 MME/day (per 25 days)

Initial 3-month Belbuca example180 films/3 months (2 films/day) for initial 3-month <90 MME/day (per 75 days)

Post-month adjustmentPost-month limit increases to 90 films/month (3 films/day) corresponding to <200 MME/day

Belbuca various strengths — per-table examples

Belbuca 75/150/300 mcg examples75–300 mcg strengths: initial 60 films/month (2/day) and initial 180/3 months (2/day) at <90 MME/day; post-month 90 films/month (3/day) at <200 MME/day

Higher-strength notesSome higher strengths (e.g., 600–900 mcg) have initial zero or restricted initial entries and may require post-limit PA for certain MME bands

Background

Extended‑release opioid formulations are intended for management of severe, persistent pain that requires around‑the‑clock, daily opioid therapy when alternative treatments are inadequate. These products (examples include buprenorphine ER formulations, fentanyl transdermal systems, hydromorphone ER, hydrocodone ER, morphine ER, methadone, and others) are not for PRN use and are generally indicated for patients with chronic or severe pain conditions who need continuous analgesia.

Because ER opioids pose greater risks of overdose and mortality than short‑acting opioids, the policy implements step therapy, MME‑based quantity limits, and prior authorization controls to ensure ER formulations are used in the intended opioid‑tolerant, continuously treated patient population and to limit use to situations where benefits outweigh risks.

Definitions

Opioid‑tolerant — definition

Opioid-tolerant definition (clinical)Patients taking ≥60 mg morphine per day (or equianalgesic dose) for 1 week or longer

PurposeDefinition used to determine eligibility for products labeled for opioid-tolerant patients (e.g., fentanyl transdermal)

Documentation implicationPrescribers should document duration and daily morphine-equivalent dose when requesting certain ER opioids

Methadone distribution for addiction

Methadone for addiction must be dispensed by OTPsMethadone used for treatment of opioid addiction (detoxification or maintenance) shall be dispensed only by certified opioid treatment programs per 42 CFR 8

Formulation restrictionCertified programs shall dispense and use methadone in oral form only for opioid agonist treatment

Revision History

2024-02-02policy_effective_dateLatest

Policy effective date set; document identifies fill-period and packaging accommodation for 30- and 90-day fills (25 and 75 days respectively) to allow refill processing and sets certain strengths with initial limit = 0 requiring post-limit prior authorization.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOpioids ER Step Therapy with MME Limit and Post Limit Prior Authorization

Policy CodePolicy 2219-M

Change TypeNo material changes

Effective DateFeb 2, 2024

Next Review DateN/A

Key ActionObtain prior authorization when step therapy or quantity/MME thresholds are not met (e.g., no ≥8-day IR or ≥30-day ER prior use, or supply corresponds to ≥90 MME/day).

SourceLink

On This Page

Fill-duration adjustment:

Unless the minimum FDA‑labeled strength/frequency exceeds 200 MME/day: a 30‑day fill is enforced as 25 days and a 90‑day fill as 75 days to allow refill processing; limits are implemented both as quantity‑vs‑time and as daily‑dose (MME/day) edits.

25 days for 30‑day fills; 75 days for 90‑day fills

Applies to quantity enforcement and daily MME edits; see policy notes for packaging accommodation and DOA for palliative care

FDA-limit exceptionIf FDA-labeled strength/dose/frequency exceeds 200 MME/day, the <200 MME/day authorization rule may not apply

MME/day thresholds — shorthand

Shorthand low threshold<90 MME/day

Shorthand high threshold<200 MME/day (authorization required unless FDA label exceeds 200 MME/day)

Supply durations referencedApplied to 30-day or 90-day supplies in the policy's quantity limits chart

Daily MME edits

Range of per-strength MME editsChart entries include per-strength daily MME edits such as 30, 45, 60, 90, 120, 180 MME/day depending on product and strength

Edits tied to quantity limitsDaily MME edits are enforced alongside 30- and 90-day quantity limits (quantity vs time and daily dose edits)

Initial-zero indicatorSome strengths show initial limit = 0 and are subject to post-limit prior authorization, which affects MME enforcement

Required prior use: ≥8 days IR opioid OR ≥30 days ER opioid within past 90 days to avoid PA trigger.
Claim behavior: Missing required prior‑use history will cause claim rejection and referral to PA unit.

Denial Risk

MME Thresholds Trigger Authorization / Denial Risk

Coverage without prior authorization is limited to 30‑ or 90‑day supplies that correspond to <90 MME/day when step therapy prerequisites are met. Requests for quantities that correspond to ≥90 MME/day (and up to <200 MME/day) or for higher MME/day supplies require authorization and may be denied if criteria are not met.

No‑auth coverage: 30‑ or 90‑day supply corresponding to <90 MME/day when step therapy met.
Authorization required: Quantities corresponding to ≥90 MME/day up to <200 MME/day require PA when coverage conditions are met.
Denial risk: Requests exceeding MME thresholds or not meeting step therapy may be denied.

Prior Authorization

Post‑Limit Prior Authorization Required for Initial‑Zero Strengths

Some drugs/strengths have an initial limit of zero and therefore require post‑limit prior authorization for any quantity. Prescribers requesting these products must submit post‑limit PA documentation for consideration.

Initial‑zero strengths: Certain strengths are set to an initial limit of 0 and require post‑limit PA for any dispensing.
Post‑limit PA process: All requests for these strengths are reviewed through the PA unit.

Documentation Required

Chronic Pain — Prescriber Documentation Requirements

Authorization for chronic pain requires documentation that the patient is appropriate for ongoing ER opioid therapy and that safety monitoring and reassessment plans are in place. Prescribers must document opioid tolerance, safety for the requested dose, monitoring plans, and reassessment schedule.

Chronic pain definition: Generally pain lasting >3 months.
Documentation: Evidence patient can safely take requested dose based on opioid history; plan for reassessment in first month after initiation/dose increase and at least every 3 months thereafter; regular monitoring for opioid use disorder.
Opioid tolerance: Document that patient is opioid‑tolerant when prescribing high‑risk products (e.g., fentanyl transdermal, hydromorphone ER).
Prerequisite: Patient must have taken an IR opioid for ≥1 week OR been on an ER opioid for ≥30 days for authorization for chronic pain.

Prior Authorization

Post‑Limit Prior Authorization and Palliative Care Duration

Post‑limit prior authorization is available for palliative care indications. When approved for palliative care or end‑of‑life care, authorizations may be granted for a duration up to 12 months.

Palliative care duration of authorization: up to 12 months.
Exemptions: Patients with cancer, sickle cell disease, palliative care diagnosis, or hospice residence in the past 365 days may follow different limits (see policy criteria).

Applies to patients without recent cancer/sickle cell/hospice/palliative indicators; see quantity limits chart columns (Initial 1 month/Initial 3 month)

Initial quantity application: Initial quantity limits (Column A/B) apply to patients meeting the initial step therapy conditions; quantities correspond to MME/day bands (<90 MME/day for no‑auth coverage when step therapy met).<90 MME/day for no‑auth when step therapy met

Quantity limits accumulate across like unit products; see chart for per‑product counts

Per-strength MME mappingDifferent strengths map to specific MME/day values in the chart (e.g., 18, 27, 36, 45, 54 MME/day per strength)

Butrans — monthly and 3-month patch limits

Butrans patch monthly limitsExamples: 4 patches/month (0.144 patch/day) at lower MME bands; 8 patches/month or 12 patches/3 months at higher post limits

Per-strength MME mappingButrans strengths (5, 7.5, 10, 15, 20 mcg/hr) are mapped to MME/day values (e.g., 13.5, 18, 27, 36 MME/day) in the chart

Some strengths initially limitedCertain higher strengths show '0***' initial limits and require post-limit prior authorization

Fentanyl transdermal — patch/day and MME/day examples

Fentanyl patch multi-strength limitsPer-table examples include 12, 25, 37.5, 50, 62.5, 75, 100 mcg/hr with per-month and 3-month patch counts tied to patch/day and MME/day (e.g., 12 mcg/hr = 0.334 patch/day -> 30 patches/3 months at 28.8 MME/day)

Higher-strength mappingsHigher strengths mapped to higher MME/day and specific month/3-month counts (e.g., 37.5 mcg/hr entries at 90 or 180 MME/day bands)

Initial-zero entriesSome fentanyl strengths (e.g., 50, 100 mcg/hr) show 0*** initial limits for certain bands and require post-limit PA

Hydrocodone ER (Zohydro) — month and 3-month caps

Hydrocodone ER (Zohydro) examplesExamples: 60 caps/month (2 caps/day) at lower MME bands; 90 caps/month (3 caps/day) at higher MME bands corresponding to increased MME/day

Strength-specific caps10–50 mg strengths mapped across months/3-months with corresponding MME/day (e.g., 20 mg = 60 caps/month = 40 MME/day)

Some strengths restrictedCertain higher strengths show '***' or initial-zero entries requiring post-limit authorization

Hydromorphone ER (Exalgo) — tablet limits

Hydromorphone ER (Exalgo) tablet limitsExamples: 8 mg — 30 tabs/month (1/day) at ~40 MME/day; higher strengths mapped to 30/60/90 tabs/month with corresponding MME/day (e.g., 16 mg = 30 tabs/month at 80 MME/day)

Higher-strength notesSome high strengths (e.g., 32 mg) show 0 or restricted initial limits and require post-limit PA for certain bands

Quantity mappingChart ties tablet counts to daily MME edits (e.g., 2 tabs/day entries equal higher MME/day bands)

Hysingla ER — monthly and 3-month tablet limits

Hysingla ER monthly limitsExamples: 30 tabs/month (1/day) for lower MME bands; 60 tabs/month (2/day) for higher MME bands; mappings vary by strength (20–120 mg)

Per-strength MME equivalentsStrengths mapped to MME/day values (e.g., 20 mg ≈ 20 MME/day; 60 mg ≈ 60 MME/day; 120 mg entries map to 120 MME/day)

Initial-zero entries for high strengthsSome high strengths (e.g., 100–120 mg) show '0' or '***' indicating initial-zero limits requiring post-limit PA

Methadone — tablet/injection/solution quantities and MME/day

Methadone conversions and quantitiesChart provides monthly and 3-month quantities converted to tablet or mL equivalents with associated MME/day (e.g., Methadone 10 mg: 90 tabs/month = 3 tabs/day ≈ 70.5 MME/day)

Liquid/injection equivalenciesInjection and oral solution volumes are converted to tab-equivalents (e.g., 200 mg/20 mL injection: 90 tabs/month = 20 mL/month ≈ 31.3 MME/day)

Multiple formulation mappingsEntries include 5 mg, 10 mg tablets and various concentrate solutions with explicit mL/day and MME/day mappings

Morphine ER (Avinza, Kadian) — monthly and 3-month caps

Morphine ER (Avinza, Kadian) caps/tablet limitsExamples: 30 caps/month (1/day) or 60 caps/month (2/day) tied to MME/day bands (e.g., Avinza 30–90 mg entries map to 4 caps/day vs 2 caps/day scenarios)

Per-strength MME mappingsStrengths include mappings to 70.5, 94, 120, 180 MME/day depending on unit counts and strength

Initial-zero/high-strength notesSome high-strength morphine ER entries show '***' or 0 indicating initial-zero limits and need for post-limit PA

Morphine ER various brands — product- and strength-specific limits

Product- and strength-specific morphine ER limitsChart lists product- and strength-specific 30- and 90-day limits with corresponding caps/day and MME/day edits (examples across Avinza, Kadian, MS Contin)

Accumulation ruleQuantities accumulate across drugs that share the same unit counts (e.g., 30-unit products accumulate together)

Some strengths initially blockedCertain strengths are marked 0*** indicating initial system limit zero and post-limit PA required

MS Contin, Nucynta ER, OxyContin — 30/90-day limits

MS Contin, Nucynta ER, OxyContin per-strength limitsChart shows per-strength 30-day and 90-day quantity limits with associated caps/day and MME/day edits; some strengths marked 0*** initial-zero

Example OxyContin 20 mg60 tabs/month (2/day) = 60 MME/day mapping; 180 tabs/3 months = 2/day over 75 days mapping

Initial-zero examplesMS Contin 60 mg and other high strengths appear as 0*** (initial zero) requiring post-limit PA

Oxymorphone ER, Tramadol ER, Xtampza ER — quantity limits

Oxymorphone ER examplesPer-strength tablet limits: e.g., 7.5 mg = 60 tabs/month (2/day) at 45 MME/day; higher strengths map to 90/270 tabs/3 months at higher MME/day bands

Tramadol ER and Xtampza entriesTramadol ER strengths include 30/90-day limits with some strengths initially blocked; Xtampza ER strengths have specific caps (e.g., 9 mg = 60 caps/month at 30 MME/day)

Initial-zero/high-strength flagsSeveral oxymorphone and Xtampza strengths show '0***' or '***' indicating initial-zero and post-limit PA requirement

Regulatory consequencesFailure to follow 42 CFR requirements may result in prosecution, seizure, revocation of approval, and injunctions

Chronic pain — definition and authorization note

Chronic pain definitionGenerally defined as pain lasting greater than 3 months

Authorization applicabilityAuthorization may be granted for chronic severe and persistent pain when criteria (safety, reassessment, monitoring, prior IR/ER use) are met

Monitoring requirementsReassessment in the first month after initiation or dose increase and every 3 months thereafter; monitor for opioid use disorder

post-limit prior authorization — definition and note

Post-limit prior authorization definitionA prior authorization process used when the initial system limit is zero for a drug/strength; prescribers must submit clinical justification for coverage consideration

Operational noteEntries marked '***' in the chart indicate initial limit = 0 and require all requests to be considered through post-limit PA

Palliative care exceptionFor palliative care, duration of authorization (DOA) is 12 months (post-limit PA may apply)