CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

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

Step therapy, quantity limits, and post-limit prior authorization criteria for extended‑release opioid analgesics; applies to pharmacy benefit management for covered members under the payer's program as implemented via CVS Caremark criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must meet class-level step therapy (prior IR or ER opioid use) and follow the charted quantity/MME limits or request prior authorization consistent with the chart.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CVS Caremarkdocument source

2219-Minternal id

≤90 MME/dayNo-PA threshold

≤200 MME/dayPA threshold

~20ER agents listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Extended‑Release Opioid Analgesics

Initial therapy / coverage conditions

Covered when ALL of the following are met (class-level statements present in excerpt):

Appropriate indication: The patient has severe, persistent pain requiring daily, around‑the‑clock, long‑term opioid treatment for which alternative treatment options are ineffective, not tolerated, or otherwise inadequate.

Derived from product indication and limitation of use statements.

Not PRN use: The requested extended‑release opioid is not intended for as‑needed (prn) analgesia and is for scheduled, around‑the‑clock use.

Multiple product limitations state ER opioids are not indicated for prn use.

Opioid tolerance where required: When the product is indicated for opioid‑tolerant patients (e.g., fentanyl transdermal system, certain hydromorphone formulations), documentation of opioid tolerance per the policy definition is provided.see policy definition

Opioid‑tolerant definitions and requirements referenced for fentanyl and hydromorphone.

Product-specific coverage criteria (indication + alternatives inadequate)

Covered when ALL of the following are met (per product indication statements in this excerpt):

Product indication: The requested product is indicated for management of severe and persistent pain that requires an extended treatment period with a daily opioid analgesic or for which alternative treatment options are inadequate.

Supported by individual product indication statements (e.g., methadone, morphine ER, Nucynta ER, Xtampza ER).

Pain associated with cancer/sickle cell/terminal/hospice

Authorization may be granted when the requested drug is prescribed for specific high-need conditions.

Covered indications: Requested drug is prescribed for pain associated with cancer, sickle cell disease, a terminal condition, or pain being managed through hospice or palliative care.

These diagnoses qualify for authorization under DOA category for high-need conditions.

Chronic pain — continuation or initiation

Authorization may be granted for chronic pain when ALL of the following are met:

Chronic pain general requirements: Pain is severe and persistent enough to require extended daily opioid therapy; the patient can safely take the requested dose; the patient will be evaluated and monitored regularly for development of opioid use disorder; pain will be reassessed in the first month after initiation or dose increase and every 3 months thereafter.

Lowest effective dose should be used; reserve higher doses only when benefits outweigh risks.

Prior opioid use requirement: Either: (1) request is for continuation of ER opioid therapy for a patient who has been receiving an ER opioid for at least 30 days; OR (2) the patient has taken an immediate‑release opioid for at least one week prior to initiation.>=30 days or >=1 week

If the request is for a methadone product, it must NOT be for detoxification or maintenance treatment of opioid addiction.

Supply/Limit Criteria

Quantity limits and permitted supply are defined per product‑strength and correlated MME/day; coverage is contingent on staying within these limits or following step‑therapy/MME policies.

Supply limit rule: Dispensing must not exceed the monthly or 3‑month tablet/capsule (or mL for liquid/injection) limits specified for the exact product and strength and the corresponding MME/day in the Opioid Analgesics ER Quantity Limits Chart.per chart entries

Some strengths/entries show '0***' indicating disallowed or restricted dispensing that would not be covered.

Quantity limits by drug/strength

Covered when dispensing is within the product-specific ER quantity limits shown in the chart

Chart-constrained coverage: Coverage is provided only if the dispensed quantity (tabs/caps per 30 days or per 90 days) and daily caps (tabs/caps per day) match one of the listed combinations for the specific drug and strength in the Opioid Analgesics ER Quantity Limits Chart.see chart entries

Chart lists allowed 30‑day and 90‑day quantities and corresponding MME/day for each product/strength.

Duration of approval

DOA rules: For pain associated with cancer, sickle cell disease, a terminal condition, or pain managed through hospice/palliative care: duration of approval = 12 months; For chronic pain: duration of approval = 6 months.12 months or 6 months

Provider must select appropriate diagnosis category for DOA determination.

Injectable methadone products are not approved for the outpatient treatment of opioid dependence. Parenteral methadone is intended only for patients unable to take oral medication (for example, hospitalized patients) and should not be used for outpatient maintenance or detoxification of opioid addiction.

Extended‑release/long‑acting opioid products are not indicated for as‑needed (prn) analgesia. Across multiple products, ER/LA formulations should be reserved for patients with severe, persistent pain requiring scheduled, daily opioid therapy when alternatives (non‑opioid analgesics or immediate‑release opioids) are ineffective, not tolerated, or otherwise inadequate. In addition, methadone formulations are not indicated for detoxification or maintenance treatment of opioid addiction except under the regulatory conditions that apply to addiction treatment programs.

Methadone prescribed for the treatment of opioid addiction must be dispensed only by opioid treatment programs certified by SAMHSA and approved by the designated state authority, in accordance with 42 CFR part 8. Certified programs should dispense methadone in oral form and follow the Federal Opioid Treatment Standards; limited regulatory exceptions exist for inpatient use or brief emergency coverage as specified in the regulations.

ER/LA opioid formulations are not appropriate for PRN (as‑needed) analgesia and should be reserved for patients for whom alternative treatments (non‑opioid analgesics or immediate‑release opioids) are ineffective, not tolerated, or inadequate. Use of ER products when alternatives would be adequate increases the risk of adverse outcomes and may be outside the policy’s coverage criteria.

The Opioid Analgesics ER Quantity Limits Chart includes multiple entries marked as "0***" for specific product‑strength and supply combinations. These chart entries indicate that particular strength/quantity combinations are excluded or require special review and are not part of the allowed dispensing options shown elsewhere in the chart.

Chart entries marked 0*** also signal that higher‑strength formulations or dosing regimens not listed in the table are not allowed. In other words, strengths, daily doses, or quantity combinations that are absent from the chart or explicitly shown as 0*** are not permitted under the quantity limits.

Use of extended‑release opioid formulations when non‑opioid analgesics or immediate‑release opioids would be adequate is considered outside appropriate use. ER/LA opioids are intended for scheduled, long‑term management of severe pain when alternatives are ineffective, not tolerated, or inadequate.

Consistent with product limitations and the plan’s step‑therapy approach, the policy states that the use of ER/LA opioid formulations when non‑opioid or immediate‑release opioid options would be adequate is not appropriate. Providers should document why alternatives are ineffective or not tolerable before seeking ER/LA coverage.

Requests for ER opioid quantities or strengths that are explicitly shown as "0***" in the quantity limits chart are not permissible and would be considered not medically necessary. Prescriptions exceeding the charted monthly or 3‑month quantities or MME/day equivalents are at risk for denial or will require prior authorization.

MME Thresholds and Coding-related Limits

MME thresholds for coverage

Coverage without prior authorizationCoverage provided without PA for 30- or 90-day supply when quantity corresponds to ≤ 90 MME/day (when Step Therapy criteria met)

Coverage with prior authorizationQuantities corresponding to ≤ 200 MME/day (for 30- or 90-day supply) are available via prior authorization when coverage conditions are met

Aggregation ruleQuantity limits accumulate across drugs with the same unit limit (e.g., 30-unit drugs accumulate together)

MME/day thresholds (examples)

Example MME tiers in chartChart entries include product/strength MME/day values such as 40 MME/day, 60 MME/day, 80 MME/day

Higher MME examples

Provider Actions, Prior Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for extended‑release/long‑acting (ER/LA) opioid products when alternative treatment options (e.g., non‑opioid analgesics or immediate‑release opioids) are ineffective, not tolerated, or otherwise inadequate. Claims for ER/LA opioids will reject and require submission of a prior authorization if the patient has not met step therapy screening (see Initial Step Therapy criteria) or when the requested quantity or morphine‑milligram‑equivalent (MME) per day exceeds the charted thresholds.

Step therapy applies at the class level; initial step requirements must be met before coverage of listed ER opioids.
Coverage without PA is limited to quantities corresponding to ≤ 90 MME/day when Step Therapy criteria are met; quantities corresponding to ≤ 200 MME/day require PA (unless FDA‑labeled dosing exceeds 200 MME/day).
Prior authorization criteria are applied to requests that fail the step therapy screen or exceed MME/quantity thresholds.

Note

Limitations of Use — Reserve for Inadequate Alternatives

Use of ER/LA opioid formulations should be reserved for patients for whom alternative treatment options are inadequate. The product‑specific Limitations of Use reinforce that these agents are not for as‑needed (prn) use and should be used only when non‑opioid and IR opioid options are ineffective or not tolerated.

Initial Therapy and Step Therapy Requirements

Initial Step Therapy

Class-level initial step therapy applies.

Class-level step therapy: Members must complete required initial step(s) per CVS Caremark step therapy before approval of extended‑release opioid formulations; initial quantity limits and MME limits apply.see step therapy rules

Applies to the ER opioid class as specified in the policy header.

Initial therapy rules

Initial coverage considerations based on limitations of use:

Reserve for inadequate alternatives: ER/LA opioid formulations are reserved for patients for whom non‑opioid analgesics or immediate‑release opioids are ineffective, not tolerated, or otherwise inadequate.

Limitations of use language repeated for multiple products.

Continuation Therapy Criteria

Continuation therapy

Continuation criteria for ER opioid therapy

Continuation eligibility: Request is for continuation of therapy for a patient who has been receiving an extended‑release opioid agent for at least 30 days.>=30 days

Continuation rule aligns with step‑therapy lookback requirements.

Quantity Limits and Product‑Specific Caps

Class-level ER opioids — MME & quantity limits

Class coveredExtended-release opioid analgesics subject to class-level MME limit and initial quantity limits per plan criteria

Supply lengthsQuantity limits specified for 30-day or 90-day supplies in the ER quantity limits chart

PA/Step therapy relationshipStep therapy must be met for no-PA coverage up to ≤ 90 MME/day; post-limit PA applies for higher MME tiers

Multiple ER opioids — chart-level limits

Variable product/strength limitsChart lists product- and strength-specific monthly and 3-month limits that correspond to ≤ 90 MME/day (no PA when step therapy met) and higher post-1 month limits up to ≤ 200 MME/day (PA required)

Examples include films and patches

Background and Scope

Extended‑release opioid analgesics are indicated for the management of severe, persistent pain requiring daily, around‑the‑clock opioid treatment when alternatives are inadequate. Many ER products are specifically intended for scheduled dosing and, for some agents, only for opioid‑tolerant patients. Because of the risks of addiction, abuse, misuse, overdose, and death, ER/LA opioids should be reserved for patients who have not achieved adequate relief with or cannot tolerate non‑opioid or immediate‑release opioid therapies.

Definitions and Key Terms

Opioid-tolerant — definition and implications

Opioid-tolerant definition (duration and doses)Opioid-tolerant patients are those taking, for one week or longer, at least 60 mg morphine/day, 25 mcg/hr transdermal fentanyl, 30 mg oral oxycodone/day, 8 mg oral hydromorphone/day, 25 mg oral oxymorphone/day, 60 mg hydrocodone/day, or an equianalgesic dose of another opioid

Clinical implicationProducts indicated for opioid-tolerant patients require documentation of tolerance to avoid denial

Applies to specific agentsFentanyl transdermal system and hydromorphone ER are explicitly noted as for opioid-tolerant patients

Methadone Intensol (oral concentrate) — indication

IndicationMethadone Intensol (oral concentrate) is indicated for management of pain severe enough to require daily, around-the-clock, long-term opioid treatment when alternatives are inadequate

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must meet class-level step therapy (prior IR or ER opioid use) and follow the charted quantity/MME limits or request prior authorization consistent with the chart.

SourceLink

On This Page

Some product-strength entries list 120 MME/day, 160 MME/day

Maximum/PA-associated tiersChart shows entries at or above 200 MME/day for certain strengths requiring special review or PA

Per-day MME thresholds (chart examples)

Per-product MME examplesChart lists per-day MME thresholds including 20, 30, 45, 60, 67.5, 80, 90 MME/day for various products/strengths

Higher per-day thresholdsChart also includes higher thresholds such as 135, 160, 180, 240 MME/day for specific strengths

Dose-to-limit mappingEach listed product/strength maps allowed tabs/caps per 30- and 90-day supply to a corresponding MME/day used for limit calculations

Reserve ER/LA opioids (including Belbuca, Butrans, methadone formulations, morphine ER, Nucynta ER, OxyContin, oxymorphone ER, tramadol ER, Xtampza ER) for inadequate alternatives.
Do not use ER/LA opioids as prn therapy.

Prior Authorization

Restricted Strengths May Require Prior Authorization

Many ER opioid strengths and formulations have restricted or non‑standard quantity entries in the Quantity Limits Chart (e.g., entries listed as “0***”), indicating those strengths may require prior authorization or are non‑covered without review. Verify strength‑specific limits before dispensing.

Restricted strengths (0*** in chart) may require PA or be non‑covered.
Pharmacists and providers should confirm allowable strengths/quantities against the Opioid Analgesics ER Quantity Limits Chart prior to fill or submission of PA.

Documentation Required

Opioid Tolerance Requirement and Documentation

Documentation of opioid tolerance is required for agents that are indicated only in opioid‑tolerant patients (for example fentanyl transdermal systems, hydromorphone ER, certain high‑strength ER opioids). Opioid tolerance is defined in product labeling (examples provided) and absence of documented tolerance may preclude approval.

Opioid‑tolerant patients: receiving for ≥1 week doses approximately ≥60 mg oral morphine/day or equivalent (examples: 25 mcg/hr transdermal fentanyl, 30 mg oral oxycodone/day, 8 mg oral hydromorphone/day, etc.).
Provide documentation of prior opioid dosing and duration to demonstrate tolerance when requesting fentanyl transdermal system or other opioid‑tolerance‑required ER agents.

Denial Risk

Denial Risk for Inappropriate ER Opioid Use and Quantity/ MME Exceedance

Requests for ER opioids that are inconsistent with step therapy, exceed the allowable MME/day thresholds, or request quantities beyond the charted monthly/3‑month limits are at risk for denial. Additionally, use of ER/LA opioids when alternative treatments would be adequate may result in denial.

Denial risk when step therapy not met or PA criteria not satisfied.
Denial risk when requested quantity corresponds to >200 MME/day (unless FDA‑labeled dosing justifies higher MME) or exceeds listed monthly/3‑month quantity limits.
Denial risk for inappropriate ER opioid use when alternatives would be adequate.

Step Therapy

Initial Step Therapy Requirements and Screen Fail → PA Required

Initial step therapy requires prior use documentation: either at least an 8‑day supply of an immediate‑release (IR) opioid in the past 90 days, or at least a 30‑day supply of an extended‑release (ER) opioid in the past 90 days (i.e., current stability on an ER opioid). If these conditions are not met the claim will reject and PA is required; the PA unit will then apply authorization criteria.

If patient has ≥8‑day IR opioid fill in past 90 days → initial quantity limits (Column A/B) apply.
If patient has ≥30‑day ER opioid fill in past 90 days → initial quantity limits (Column A/B) apply.
If neither condition met → claim rejects with prior authorization required.

Documentation Required

Clinical Monitoring, Prior Use, and Regulatory Documentation

Clinical monitoring and prior use documentation must be provided with PA requests for chronic pain: patient evaluation showing safe use of the requested dose based on opioid history, a plan for regular monitoring for opioid use disorder, and a plan for pain reassessment (within the first month after initiation or dose increase, then at least every 3 months). For methadone products, verify the indication is not for detoxification or maintenance treatment for opioid addiction.

Document that the patient will be monitored regularly for development of opioid use disorder.
Document pain reassessment schedule: within 1 month of initiation/dose increase and every 3 months thereafter.
For methadone, include documentation that use is not for detoxification or opioid‑addiction maintenance and abide by 42 CFR §8 distribution rules when applicable.

Billing Rule

Dispensing Verification and Quantity Limit Adherence

Pharmacists must verify dispensing aligns with the Opioid Analgesics ER Quantity Limits Chart: confirm the allowed monthly or 3‑month tablet/capsule/film counts and corresponding MME/day before dispensing. Requests exceeding the charted supplies should be referred for PA.

Pharmacists should confirm product, strength, units/month and MME/day per the chart prior to fill.
If dispensing would exceed allowable monthly/3‑month counts or MME thresholds, require PA prior to release.

Documentation Required

Diagnosis Documentation and Duration of Approval (DOA)

Duration of approval (DOA) depends on diagnosis: pain associated with cancer, sickle cell disease, terminal conditions, or hospice/palliative care: DOA = 12 months. Chronic pain: DOA = 6 months. Ensure diagnosis documentation is included with PA requests to support the requested DOA.

Provide supporting diagnosis codes/documentation to substantiate cancer, sickle cell disease, palliative/hospice care, or chronic pain.
DOA: 12 months for cancer/sickle cell/terminal/hospice/palliative; 6 months for chronic pain.

Not PRN: ER/LA formulations are not indicated for as‑needed (prn) analgesia.

Repeated across product limitation statements.

Initial therapy rules

Initial step therapy and quantity limits

Initial step therapy requirement: For patients without recent cancer/sickle‑cell/palliative/hospice indicators: the patient must have filled at least an 8‑day supply of an immediate‑release (IR) opioid in the past 90 days OR at least a 30‑day supply of an ER opioid in the past 90 days to meet initial step therapy; if not met, the claim will reject and prior authorization is required.8‑day IR or 30‑day ER in past 90 days

If the step is met, initial quantity limits per Column A/B of the chart apply.

Requirement	Details
Complete CVS Caremark step therapy
Initial step therapy must be met for the extended‑release opioid class prior to approval; see policy header and step therapy section.

Requirement	MME implication / Action
Step therapy applies with MME limits
Policy header: step therapy is implemented together with MME/day limits; coverage and post‑limit prior authorization are determined by the charted MME thresholds (e.g., ≤90 MME/day no PA when step met; higher MME may require PA).

Prior use required to meet initial step	Consequence if not met
At least an 8‑day supply of an immediate‑release (IR) opioid within the past 90 days
If not present (no qualifying IR ≥8 days or ER ≥30 days in past 90 days), the claim will reject and prior authorization is required.

Framework element	Description
Class‑level step therapy
Step therapy applies to the extended‑release opioid class; initial steps must be completed before ER opioid coverage is allowed.
MME limits integrated
Policy implements MME/day limits alongside step therapy; allowable quantities and need for PA depend on charted MME thresholds.

Member requirement	Implication for higher quantities/strengths
Meet step therapy prior‑use criteria (IR ≥8 days or ER ≥30 days) and adhere to charted MME/day limits
Only after meeting the step therapy prior‑use rule and remaining within the charted MME/day and monthly/90‑day quantity limits will higher quantities or higher‑strength entries be eligible for coverage; otherwise PA or denial may result.

Belbuca film and Butrans patch entries show 30- and 90-day quantities with associated MME/day tiers

Tab/cap accumulationLimits are expressed as tabs/caps per 30 days and per 90 days with corresponding tabs/caps per day and MME/day for each strength

Hydrocodone ER (Zohydro ER) — sample monthly & 3-month limits

Common monthly limit examplesZohydro ER 10 mg: 60 caps/month (2 caps/day) = 20 MME/day; Zohydro ER 20 mg: 60 caps/month (2 caps/day) = 40 MME/day

3-month supply examplesZohydro ER 10 mg: 180 caps/3 months (2 caps/day); Zohydro ER 20 mg: 180 caps/3 months (2 caps/day)

Higher-strength PASome Zohydro ER strengths (e.g., 50 mg) are listed as 0*** (restricted) or require special review for higher MME/day

Hydromorphone ER (Exalgo) and Hysingla ER — monthly/3-month limits

Typical monthly capsHydromorphone ER (Exalgo) 8 mg: 30 tabs/month (1 tab/day) = 40 MME/day; 16 mg: 30 tabs/month (1 tab/day) = 80 MME/day

3-month examplesExalgo 16 mg: 90 tabs/3 months (1 tab/day) = 80 MME/day; Hysingla ER 20 mg: 30 tabs/month (1 tab/day) = 20 MME/day

Higher-dose entriesSome strengths show 0*** (restricted) or higher MME/day entries that require PA or are limited to patch-equivalent accumulations

Methadone — tablet, injection, and oral solution quantity/volume mappings

Tablet monthly mappingMethadone 5 mg: 90 tabs/month (3 tabs/day) = 70.5 MME/day; Methadone 10 mg: 90 tabs/month (3 tabs/day) = 70.5 MME/day

Injection/solution conversionsMethadone 200 mg/20 mL injection: 20 mL/month = 0.667 mL/day = 31.3 MME/day; Methadone Intensol 10 mg/mL: 45 mL/month = 1.5 mL/day = 70.5 MME/day

Higher-volume limitsOral solutions and larger tab quantities map to higher mL/month or tab/month equivalents with corresponding MME/day used for limit determination

Morphine ER (Avinza, Kadian, MS Contin) — strength-specific limits

Avinza/MS Contin examplesMorphine ER (Avinza) 45 mg: 90 tabs/month (3 tabs/day) = 70.5 MME/day; 60 mg: 90 tabs/month (3 tabs/day) = 70.5 MME/day with cap-to-cap mappings to capsule equivalents

Strength restrictionsSome high-strength morphine ER entries are shown as 0*** indicating disallowed or restricted dispensing for those strength/quantity combinations

Chart-based MME mappingEach morphine ER strength lists specific monthly and 3-month tablet/capsule limits with an associated MME/day for adjudication and PA determination

Nucynta ER, OxyContin, Oxymorphone ER — sample limits & MAX statements

Nucynta ER exampleNucynta ER 100 mg: 60 tabs/month (1 cap/day) = 80 MME/day; higher strengths list 0*** for some rows and 2 caps/day options equating to 160-200 MME/day

OxyContin examplesOxyContin 10-30 mg entries show 60 tabs/month or 90 tabs/month options mapping to 30-90 MME/day; higher strengths include 2 caps/day options up to 135-180 MME/day

Product max statementsSome agents include MAX mg/day statements (e.g., Nucynta ER MAX 500 mg/day) used alongside tab/cap limits for safety

Multiple ER opioids — product & strength specific 30-/90-day limits

Per-30/90-day tab/cap mappingChart lists product- and strength-specific tabs/caps per 30 days and per 90 days with the corresponding tabs/caps per day and MME/day for each entry

Examples across productsOxyContin, Oxymorphone ER, and others show combinations of 60/90/180/270 tabs with 1-3 tabs/day and mapped MME/day values

Restricted entries indicatedMultiple entries are marked 0*** indicating disallowed strength/quantity combinations that require special review or are not covered

Use limitationReserve for patients when alternative treatment options are ineffective, not tolerated, or inadequate

Not for addiction treatment in outpatient settingSeparation of methadone analgesic use from methadone for addiction treatment is noted elsewhere in policy guidance

Morphine sulfate extended-release — indication & limitations

IndicationMorphine sulfate extended-release is indicated for management of severe and persistent pain requiring an extended treatment period with a daily opioid analgesic when alternatives are inadequate

LimitationsReserve for patients where non-opioid analgesics or immediate-release opioids are ineffective, not tolerated, or inadequate; not indicated for as-needed (prn) analgesia

MonitoringUse should consider risks of addiction, overdose, and death associated with ER/LA formulations

Xtampza ER — indication and limitation

IndicationXtampza ER (oxycodone ER) is indicated for management of severe, persistent pain requiring daily opioid therapy

Not indicated for PRN useXtampza ER is not indicated for as-needed (prn) analgesia and should be reserved when alternatives are inadequate

Use caution with higher dosesReserve titration to higher doses only when benefits outweigh substantial risks; monitoring required

Chronic pain — definition & authorization context

Definition of chronic painChronic pain is generally defined as pain that typically lasts greater than 3 months

Authorization contextChronic pain authorization requires patient evaluation, monitoring, and reassessment in first month and every 3 months thereafter

Continuation criteriaContinuation considered when patient has been receiving an ER opioid for at least 30 days or has taken an IR opioid for at least one week

MME/day — role in chart and limits

MME/day usage in chartMME/day (morphine milligram equivalents per day) is referenced alongside each product/strength to express opioid potency equivalence for limit calculations

PurposeUsed to map allowed daily caps and monthly/90-day quantities to an equivalent opioid potency for adjudication and PA decisions

Displayed across entriesChart entries list the MME/day for each product-strength combination to guide quantity limits

MME — chart entries and equivalence

Chart MME entriesMME values are listed per product and strength (e.g., entries showing 30, 45, 60, 90, 135, 180 MME/day) corresponding to allowed daily caps

Equivalence mappingEach chart entry maps tabs/caps per day and per 30/90-day supply to an explicit MME/day equivalence for limit enforcement

Used for PA thresholdsThe MME/day equivalence determines whether an entry falls within the ≤ 90 MME/day no-PA tier or requires PA up to ≤ 200 MME/day