CurrentNeighborhood Health Plan of Rhode IslandPolicy 2219-M

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

Defines step therapy, quantity (MME) limits, and post-limit prior authorization criteria for extended-release (ER) opioid analgesics for payor-covered members; applies to prescribing providers requesting coverage 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 Criteria

Policy CodePolicy 2219-M

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for initial ER opioid therapy, initial quantity limits, and any post-limit coverage per the step therapy and MME-based quantity chart.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20listed ER opioid entries

≤90 MME/dayNo-PA threshold

≤200 MME/dayPA threshold

60 mg/dayOpioid-tolerant example

Not indicatedPRN not indicated

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Coverage Criteria for Extended‑Release Opioid Analgesics

Covered with clinical criteria

Covered when ALL of the following clinical conditions are met:

General ER opioid coverage conditions: Patient has severe, persistent pain requiring daily or around-the-clock opioid therapy; alternative treatment options (non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or inadequate.

Applies across listed ER opioid products

Opioid-tolerant requirement where applicable: Patient is opioid-tolerant when required by product labeling (examples: ≥60 mg oral morphine/day or equianalgesic dose) OR the specific product labeling does not require opioid-tolerance for use.See opioid-tolerant definitions in product sections

Fentanyl transdermal system and some ER products explicitly require opioid-tolerant status

Not for as‑needed use: Requested extended‑release opioid is prescribed for scheduled (not as‑needed/prn) use consistent with labeled Limitations of Use.

Most ER opioid product Limitations of Use state not indicated as prn

Product labeling coverage criteria — Covered when ALL of the following are met (product labeling common criteria)

Covered when ALL of the following are met (product labeling common criteria):

Product labeling criteria: 1) The patient has severe and persistent pain requiring daily, around‑the‑clock, long‑term opioid treatment per the product indication; 2) Alternative treatments (non‑opioid analgesics or immediate‑release opioids) are ineffective, not tolerated, or inadequate; 3) The product is prescribed for scheduled (not as‑needed/prn) use and used consistent with labeled Limitations of Use.

Sourced from product indications and Limitations of Use across listed ER opioid products

Methadone distribution conditions — Special distribution/coverage rules for methadone when used for opioid addiction

Special distribution/coverage rules for methadone when used for opioid addiction:

Methadone for addiction: Methadone used for detoxification or maintenance treatment of opioid addiction must be dispensed only by certified opioid treatment programs (OTPs) per 42 CFR 8, except during inpatient care for a non‑addiction primary diagnosis or an emergency period of up to 3 days as allowed by regulation.

Failure to comply with 42 CFR 8 may result in regulatory penalties

Pain associated with cancer, sickle cell disease, terminal condition, hospice/palliative care — Authorization may be granted for these conditions

Authorization may be granted when the requested drug is prescribed for these specific conditions:

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

Requests with documentation of these conditions are screened out to the prescription benefit pathway

Chronic pain — continuation or initiation with prior opioid exposure; ALL of the following are met

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

General monitoring and safety requirements: Patient can safely take the requested dose based on opioid history; lowest effective dose will be used; patient will be evaluated and monitored regularly for opioid use disorder; pain will be reassessed within the first month after initial prescription or any dose increase and at least every 3 months thereafter.

Reserve higher titration only when benefits outweigh risks

Prior opioid exposure: Either: continuation of therapy for a patient who has been receiving an extended‑release opioid for at least 30 days OR the patient has taken an immediate‑release opioid for at least one week (at least an 8‑day supply) within the past 90 days.ER ≥30 days OR IR ≥8 days in past 90 days

If prior exposure not met, claim rejects and PA is required

Methadone restriction for addiction treatment: If the request is for a methadone product, it must NOT be for detoxification or as part of a maintenance treatment plan for opioid/substance use disorder.

Quantity limits by MME and product (Initial and Post limits)

Coverage provided according to MME-based quantity limits and product-specific numeric caps:

MME-based initial and post limits: Coverage without prior authorization available for 30‑day or 90‑day supplies that correspond to ≤ 90 MME/day when Step Therapy criteria are met; coverage for quantities corresponding to ≤ 200 MME/day is available through prior authorization when coverage conditions are met. Product‑specific monthly and 3‑month numeric limits are tabulated in the Opioid Analgesics ER Quantity Limits Chart.≤ 90 MME/day (initial without PA); ≤ 200 MME/day (post with PA)

Quantity limits accumulate across drugs with identical unit limits (e.g., 30‑unit bottles accumulate together)

Quantity limits + Duration of Approval — Covered when dispensing is within drug- and strength-specific quantity limits and assigned duration matches indication

Covered when dispensing is within the drug‑ and strength‑specific quantity limits and assigned duration of approval matches the indication

Quantity and MME alignment: Dispensed quantity must not exceed the listed tabs/caps per month or per 3 months for the specific ER opioid formulation and strength; daily dosing must align with the listed tabs/caps per day and corresponding MME/day in the chart.Per the opioid ER quantity limits chart (examples: 60–270 tabs/3 months depending on strength; specific MME/day listed per item)

See chart entries (chunks 72–78) for drug‑ and strength‑specific values

Duration of approval by indication: Approval duration is assigned based on indication: pain associated with cancer, sickle cell disease, terminal condition, or hospice/palliative care → DOA 12 months; chronic pain → DOA 6 months.Indication determines DOA (12 or 6 months)

Chunk 79

Injectable methadone formulations are not approved for outpatient treatment of opioid dependence. Per product limitations, parenteral methadone is intended only for patients unable to take oral medication (for example, hospitalized patients). Requests to dispense injectable methadone for outpatient addiction detoxification or maintenance are outside the indicated distribution conditions and are restricted by federal OTP rules (42 CFR 8).

Extended‑release opioid products and methadone formulations are not indicated for as‑needed (prn) analgesia. Product labeling consistently directs reserving ER/long‑acting opioids for patients who require scheduled, around‑the‑clock therapy because non‑opioid or immediate‑release opioid options are ineffective, not tolerated, or inadequate. Use as PRN analgesia therefore does not align with the labeled indication and may be subject to restriction or denial.

Xtampza ER is explicitly not indicated as an as‑needed (prn) analgesic. Labeling and the policy advise that extended‑release opioids such as Xtampza ER be reserved for patients for whom alternatives (non‑opioid analgesics or immediate‑release opioids) are ineffective, not tolerated, or otherwise inadequate to manage severe, persistent pain requiring scheduled, around‑the‑clock treatment.

Certain product‑strength rows in the quantity limits chart are marked '0***', indicating those specific strength/quantity combinations are excluded or blocked from dispensing under the standard limits. Examples appear across products (for example, some Hydrocodone ER 50 mg entries, Hydromorphone ER 32 mg entries, Hysingla ER 100 mg/120 mg and several high‑strength morphine ER rows) and reflect formulations or dosing rows the plan will not authorize at the listed quantity.

Chart entries labeled '0***' denote formulations or strength rows with no quantity allowed under the policy's standard monthly/3‑month limits. These entries function as blocked items in the opioid ER quantity limits chart and should be treated as excluded for routine dispensing.

Requests for formulations, strengths, or quantity levels that exceed the listed chart limits — including any rows marked '0***' — are not supported by the quantity limits chart and therefore do not meet the policy's standard coverage criteria. Such requests will require additional justification and will be subject to denial if they cannot be authorized through the prior authorization process.

MME and Opioid‑Tolerance Thresholds

Opioid‑tolerant threshold examples

Opioid‑tolerant examplePatient receiving ≥ 60 mg oral morphine/day (or equianalgesic doses such as 25 mcg/hr transdermal fentanyl, 30 mg oral oxycodone/day, 8 mg oral hydromorphone/day, 25 mg oral oxymorphone/day, 60 mg oral hydrocodone/day) for one week or longer

Fentanyl transdermal example25 mcg/hr transdermal fentanyl per hour (one week or longer) meets opioid‑tolerant threshold

Oxycodone example30 mg oral oxycodone/day for one week or longer meets opioid‑tolerant threshold

MME thresholds

Covered without PA (when Step Therapy met)Quantities corresponding to ≤ 90 MME/day are covered without prior authorization if Step Therapy criteria are satisfied

PA required for higher MME

Prescriber Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization: verify indication and alternatives

Prior Authorization Required. Prescribers must document that alternatives were ineffective or not tolerated before initiating an ER opioid. For initial step therapy, claims will reject without prior exposure to an IR opioid (≥8 days) or an ER opioid (≥30 days) as specified — submit PA with documentation of prior therapies and reason alternatives are inadequate.

Document prior trial of non-opioid analgesics or immediate-release opioids and why inadequate
If step therapy screen fails, PA required and claims will reject without PA

Documentation Required

Methadone distribution: certification requirement

Methadone products prescribed for pain must not be for detoxification or maintenance treatment of opioid addiction. Dispensing methadone for opioid addiction (detoxification/maintenance) is restricted to SAMHSA-certified opioid treatment programs per 42 CFR and related regulations; during inpatient care or brief emergency exceptions apply. Failure to comply may result in regulatory penalties.

Initial Step Therapy and Initial Limit Requirements

Initial Step Therapy / Initial Limit — initial step therapy and initial limit PA conditions apply to listed ER opioids

Initial step therapy and initial limit prior authorization conditions apply to listed ER opioids:

Initial step therapy requirement: Prescriber must follow the plan's step therapy process and obtain prior authorization for initial ER opioid therapy and initial quantity limits as specified by the plan; the step therapy program applies to the listed ER opioid class and named products.

Detailed step sequences are part of the step therapy framework (policy title and list in chunks 0 and 4)

Initial therapy — initial use should be reserved for patients meeting labeling criteria

Initial use should be reserved for patients meeting product labeling criteria:

Initial therapy labeling requirement: Product should be used only when non‑opioid analgesics or immediate‑release opioids are ineffective, not tolerated, or inadequate; ER products are not indicated for as‑needed (prn) analgesia.

Continuation Therapy

Continuation therapy — continuation for patients already on ER opioids

Continuation criteria for patients already on ER opioids:

Continuation: Request for continuation of therapy meets criteria when the patient has been receiving an extended‑release opioid agent for at least 30 days.ER ≥30 days

Supports chronic pain continuation authorization

Step Therapy Tables and Requirements

Requirement	Details
Prescriber must trial alternatives per step therapy before ER opioid authorization
Per INITIAL STEP THERAPY: patient must have filled at least an 8-day supply of an immediate‑release (IR) opioid within the past 90 days or at least a 30‑day supply of an extended‑release (ER) opioid within the past 90 days; otherwise the claim will reject and prior authorization is required.

Requirement	Details / Rationale
Reserve ER/LA opioids and methadone for patients who have failed or cannot use alternatives
Limitations of Use across products state these long‑acting/extended‑release opioids and methadone should be reserved for patients for whom non‑opioid analgesics or immediate‑release opioids are ineffective, not tolerated, or otherwise inadequate; many products are not indicated for as‑needed (prn) use.

Requirement	Policy application
Prior exposure to IR or ER opioid required before ER opioid coverage without PA
INITIAL STEP THERAPY: to qualify for initial quantity limits without prior authorization, the member must have an IR opioid claim ≥8 days supply in the past 90 days or an ER opioid claim ≥30 days supply in the past 90 days; otherwise the claim will reject and PA criteria apply.

Statement	Notes
This section is part of a step therapy policy with MME limits
The policy functions with step therapy plus MME‑based quantity limits (see Opioid Analgesics ER Quantity Limits Chart); specific step sequences or detailed step requirements are not provided in the excerpted chunks.

Title implication	Availability of step sequences
Policy title indicates step therapy applies to Opioids ER
Although the document title and framework specify step therapy for ER opioids, the specific step sequences and failure criteria are not present in the provided chunks; see quantity limits chart and initial step therapy rules for related requirements.

Product‑ and Strength‑Specific Quantity Limits (Monthly and 3‑Month)

Extended‑release opioids — class‑level limits

Class‑level ruleExtended‑release opioid analgesics are subject to MME‑based quantity limits and post‑limit prior authorization per the Opioids ER policy

Coverage contingent on Step TherapyCoverage without PA limited to quantities ≤ 90 MME/day when Step Therapy criteria are met; higher MME requires PA

Quantity chart governs PAPrior authorization and post‑limit coverage are governed by the drug‑ and strength‑specific quantity limits shown in the ER quantity limits chart

Selected ER opioids — product‑specific numeric limits

Product‑specific numeric limitsChart shows units per ~25‑day (≈1 month) and per ~75‑day (≈3 months) windows with corresponding MME/day for each product and strength

Examples included

Opioid Treatment Program and Site‑of‑Care Rules

Note

Methadone for addiction: OTP dispensing and exceptions

Methadone for addiction must be dispensed by certified opioid treatment programs; inpatient and brief emergency exceptions apply as described in federal regulations.

Exceptions: inpatient care for a non‑addiction primary diagnosis and emergency periods ≤3 days while definitive care is sought.

Definitions and Key Terms

Opioid‑tolerant — definition

Opioid‑tolerant definitionPatient receiving for one week or longer at least 60 mg oral morphine/day, 25 mcg transdermal fentanyl/hr, 30 mg oral oxycodone/day, 8 mg oral hydromorphone/day, 25 mg oral oxymorphone/day, 60 mg oral hydrocodone/day, or an equianalgesic dose of another opioid

TimeframeTolerance defined as use for one week or longer

PurposeUsed to determine eligibility for certain ER opioid products that require opioid‑tolerant status

Opioid treatment program (OTP) — definition

OTP definitionOpioid Treatment Programs (OTPs) are programs certified by SAMHSA and approved by the state authority, authorized to dispense methadone for addiction treatment under 42 CFR 8

Dispensing restriction

Background

Extended‑release opioid analgesics are indicated for the management of severe, persistent pain requiring around‑the‑clock, extended daily opioid therapy when alternative treatments are ineffective, not tolerated, or inadequate. Because ER/long‑acting opioids carry greater risks (addiction, misuse, overdose and death), they should be reserved for patients who require scheduled, continuous opioid treatment and, where applicable, for patients documented as opioid‑tolerant. Authorization and quantity limits are governed by drug‑ and strength‑specific monthly and 3‑month caps and corresponding MME/day conversions; duration of approval is assigned by indication (for example, 12 months for cancer/sickle cell/terminal/hospice/palliative care and 6 months for chronic pain).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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

Policy CodePolicy 2219-M

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for initial ER opioid therapy, initial quantity limits, and any post-limit coverage per the step therapy and MME-based quantity chart.

SourceLink

On This Page

Methadone for addiction is governed by OTP rules (42 CFR 8)

Prior authorization is required for quantities corresponding to > 90 MME/day up to ≤ 200 MME/day when coverage conditions are met

MME accumulation noteQuantity limits accumulate across drugs of the same unit limit (e.g., 30‑unit products accumulate together)

Prior exposure thresholds

IR prior exposureAt least an 8‑day supply of an immediate‑release (IR) opioid within the past 90 days

ER prior exposureAt least a 30‑day supply of an extended‑release (ER) opioid within the past 90 days

Consequence if not metIf neither threshold is met, the claim will reject and prior authorization is required

Daily MME thresholds shown per regimen

Examples of MME/day per regimenChart lists regimen‑specific MME/day examples such as 40 MME/day, 80 MME/day, 135 MME/day, 160 MME/day

Hydrocodone ER examplesHydrocodone ER 20 mg: 60 caps/month = 2 caps/day (40 MME/day); 40 mg: 60 caps/month = 2 caps/day (80 MME/day)

OxyContin examplesOxyContin 30 mg: rows show 2 caps/day (80 MME/day) and 3 caps/day (135 MME/day) depending on strength and column

Tramadol ER maximum

Tramadol ER maximum daily doseMaximum 300 mg/day (MAX 300 mg/day)

Example quantity rowsTramadol ER 100 mg: 30 tabs/month = 1 tab/day (20 MME/day) and 60 tabs/month = 2 tabs/day (40 MME/day)

Higher strength notesSome Tramadol ER strength rows are listed as 0*** and therefore blocked under standard limits

Xtampza ER maximum

Xtampza ER maximum daily doseMaximum 288 mg/day (MAX 288 mg/day)

Example quantity rowsXtampza ER 9 mg: 60 caps/month = 2 caps/day (30 MME/day); 27 mg: 60 caps/month = 2 caps/day (90 MME/day)

Blocked strengthsSome higher Xtampza ER strengths (e.g., 36 mg in some columns) are listed as 0*** and not allowed under standard limits

Methadone for addiction treatment must be dispensed only by certified OTPs (42 CFR §8) except narrow inpatient/emergency exceptions
When requesting methadone for chronic pain, include statement that it is NOT for addiction treatment

Prior Authorization

Prior authorization tied to quantity/MME limits

Quantity limits and MME thresholds are enforced via the Opioid Analgesics ER Quantity Limits Chart. Coverage without PA is allowed for quantities corresponding to ≤90 MME/day when step therapy criteria are met. Quantities corresponding to >90 up to ≤200 MME/day require prior authorization and clinical justification.

Requests exceeding the listed per-day, per-month, or 3-month limits require PA
PA approval pathways exist for up to ≤200 MME/day when conditions are met

Denial Risk

Limitations of use may trigger denial

Limitations of use from product labeling are enforced and may trigger denial if the request is inconsistent with labeled indications (e.g., prn use, use when alternatives not trialed). Requests for ER opioids reserved for patients in whom alternatives are effective/intolerant may be denied.

ER opioids are not indicated as as‑needed (prn) analgesics — PA may be denied for PRN requests
Reserve ER opioids for patients with inadequate response/intolerance to alternatives; lack of documentation may result in denial

Documentation Required

Opioid‑tolerant documentation

Document opioid-tolerant status when required by product labeling (e.g., fentanyl transdermal, hydromorphone ER, OxyContin for certain pediatric/clinical scenarios). Provide evidence of at least one week of the specified opioid dose equivalence when asserting tolerance.

Specify opioid(s), dose and duration supporting opioid-tolerant status (e.g., ≥60 mg morphine/day for ≥7 days or equianalgesic dose)
Attach dosing history or prescription fill records to PA request

Documentation Required

Cancer/sickle cell/palliative/hospice screening documentation

Screen patients for cancer, sickle cell disease, palliative care, or hospice residence using prescription fill history and ICD-10 claims/member profile. If present within the past 365 days (or hospice residence code on claim), the request will be paid under the relevant prescription benefit and step-therapy/limits may not apply.

Search prescription claims for cancer/sickle cell drugs in past 365 days
Include ICD-10 codes for cancer, sickle cell, or palliative care on the claim or provide member health profile evidence
If hospice residence code is present on claim, process under hospice benefit

Billing Rule

Align prescription to charted limits

Align the prescribed quantity, days’ supply, and MME calculation to the charted limits when submitting PA. Discrepancies between the prescription and the Quantity Limits Chart (per-day, per-month, per-3-month) must be justified in the documentation to avoid denial.

Confirm per-day MME and corresponding monthly/3-month unit limits from the chart
If requesting an amount above the charted limit, provide clinical rationale and calculation of total MME/day

Documentation Required

Clinical justification for Duration of Approval (DOA)

Provide clinical justification for the requested Duration of Approval (DOA). Use the policy categories to support the DOA: 12 months for cancer/sickle cell/terminal/palliative/hospice pain; 6 months for chronic non‑cancer pain. Specify the clinical category in the PA to justify longer approvals.

Indicate whether request is for cancer/sickle cell/terminal/palliative/hospice pain (DOA 12 months) or chronic pain (DOA 6 months)
Include clinical notes supporting the selected category and expected monitoring plan

Note

Labeling consistently advises reserving ER opioids and methadone

Labeling consistently advises reserving ER opioids and methadone for patients when alternative treatments (non‑opioid analgesics or immediate‑release opioids) are ineffective or not tolerated. Ensure documentation demonstrates alternatives were tried and why they were inadequate before requesting ER therapy.

Document prior non‑opioid and IR opioid trials and reasons for ineffectiveness or intolerance
Explicitly note why ER therapy is necessary over alternative options

Consistent Limitations of Use language across product sections

Initial therapy — initial dispensing rules and limits

Initial dispensing rules and limits for eligibility without prior authorization:

Initial exposure requirement for initial limits without PA: Patient must have filled an IR opioid for at least an 8‑day supply OR an ER opioid for at least a 30‑day supply within the past 90 days to qualify for initial quantity limits without prior authorization.IR ≥8 days supply OR ER ≥30 days supply in past 90 days

If not met, the claim will reject and a prior authorization is required

Products with table entries include Belbuca, Butrans, ConZip, fentanyl transdermal, hydrocodone ER, hydromorphone ER, and others

Columns explainedColumns represent Initial 1 month, Initial 3 month, Post 1 month, Post 3 month limits corresponding to ≤ 90 MME/day (initial) and ≤ 200 MME/day (post) where applicable

Hydrocodone ER (Zohydro ER) — example caps and MME/day

Monthly cap exampleHydrocodone ER (Zohydro) 20–40 mg: typical initial limit = 60 caps/month (2 caps/day)

3‑month cap exampleHydrocodone ER 20–40 mg: up to 180–270 caps/3 months (varies by strength and column) — some rows show 270 caps/3 months = 3 caps/day

MME/day equivalentsChart provides per‑day MME equivalents for those caps (examples include 40 MME/day for 20 mg, 80 MME/day for 40 mg entries)

Hydromorphone ER (Exalgo) — example limits

Monthly limitsHydromorphone ER (Exalgo) 8–16 mg: examples include 30 tabs/month (1/day) up to 60 tabs/month or 90 tabs/3 months depending on strength and column

3‑month limits and blocked strengthsSome higher strengths (e.g., 32 mg) are listed as 0*** in certain initial columns; other columns show 30–180 tabs/3 months depending on regimen

MME/day conversionsPer‑row MME/day values are provided (e.g., 8 mg = 40 MME/day; 16 mg = 80 MME/day; 32 mg rows may show 160 MME/day in some columns)

Hysingla ER — example limits

Monthly exampleHysingla ER (20–80 mg): common initial limit = 30 tabs/month (1 tab/day) with corresponding MME/day listed per strength (e.g., 20 mg = 20 MME/day)

3‑month exampleHysingla ER: 90 tabs/3 months (1/day) up to 180 tabs/3 months (2/day) depending on strength and column

Blocked high strengthsSome strengths (e.g., 100 mg and 120 mg) are listed as 0*** in initial columns and have limited allowances in other columns

Methadone — formulations, monthly/3‑month examples and MME/day

Formulations and conversion examplesMethadone entries include tablets, oral solution, intensol and injections with examples converting to monthly/3‑month quantities and MME/day (e.g., Methadone 5 mg: 90 tabs/month = 3/day = 70.5 MME/day)

Solution and vial conversionsMethadone oral solutions and injections are converted to mL/month or mL/3 months equivalents with corresponding MME/day (examples in chunks 60–61)

Higher daily capsSome methadone rows show 4 tabs/day or higher with corresponding higher MME/day values (e.g., 4 tabs/day = 94 MME/day depending on strength/formulation)

Morphine ER (Avinza, Kadian) — example caps and MME/day

Multiple caps/tabs examplesMorphine ER (Avinza, Kadian) entries show multiple monthly and 3‑month caps (e.g., 30 caps/month, 60 caps/month, 90 caps/3 months, 180 caps/3 months) with MME/day conversions per strength

High strength restrictionsSome high‑strength morphine ER rows are marked 0*** (no quantity allowed) in certain columns

Per‑day MME conversionsExamples include 70.5 MME/day and 94 MME/day values tied to specific tab counts and strengths

Nucynta ER (tapentadol ER) — tablet limits and MME/day

Monthly tablet capsNucynta ER (50–250 mg) examples show monthly limits such as 60 tabs/month (2/day) up to 270 tabs/3 months depending on strength and column

Some strengths blockedSeveral Nucynta ER strengths are set to 0*** in certain initial columns and allowed only in post columns at different limits

MME/day equivalentsChart provides per‑row MME/day equivalents for each tablets/day regimen (examples: 80 MME/day, 160 MME/day)

OxyContin and Oxymorphone ER — example caps and MME/day

OxyContin and oxymorphone examplesOxyContin (10–80 mg) and Oxymorphone ER rows show monthly and 3‑month caps (e.g., 60 tabs/month up to 270 tabs/3 months) with MME/day equivalents

OxyContin 30–80 mg example rowsOxyContin 30 mg: 60 tabs/month (2/day) up to 270 tabs/3 months (3/day); higher strengths show mixed 0*** and allowed rows

Oxymorphone ER examplesOxymorphone ER 5–40 mg rows include 60 tabs/month and 270 tabs/3 months entries; some mid/high strengths are listed as 0***

OxyContin 30–80 mg — example rows

Sample rows for OxyContin 30–80 mgExample: OxyContin 30 mg = 60 tabs/month (2 tabs/day) up to 270 tabs/3 months (3 tabs/day); other strengths vary with some 0*** entries

Higher strength notesOxyContin 40–80 mg rows include 0*** in some initial columns with specific post‑column allowances (e.g., 2 caps/day entries)

MME/day examplesPer‑row MME/day values shown (e.g., 80 MME/day, 135 MME/day, 160 MME/day) depending on strength and column

Oxymorphone ER (5–40 mg) — example rows

Oxymorphone ER example strengthsOxymorphone ER 5–40 mg rows include 60 tabs/month and 270 tabs/3 months examples; several mid/high strengths show 0*** in initial columns

Specific blocked entriesSome Oxymorphone strengths (e.g., 20 mg, 30 mg, 40 mg) have 0*** in particular columns indicating no quantity allowed under standard limits

MME/day conversionsChart rows include per‑day MME conversions up to 240 MME/day for the highest allowed regimens

Tramadol ER examples and MAX 300 mg/day

Tramadol ER examples and maxTramadol ER 100–300 mg rows include monthly and 3‑month examples (e.g., 30 tabs/month = 1/day; 60 tabs/month = 2/day) and note MAX 300 mg/day

Per‑day MME examplesPer‑row MME/day values shown (e.g., 20 MME/day for 100 mg 1/day; 60 MME/day for 300 mg 1/day entries)

Blocked rowsSome higher strength rows for 200 mg and 300 mg forms show 0*** in certain initial columns

Xtampza ER examples and MAX 288 mg/day

Xtampza ER caps and maxXtampza ER 9–36 mg rows show monthly and 3‑month caps (e.g., 60 caps/month up to 270 caps/3 months) and state MAX 288 mg/day

Example per‑day MMEXtampza ER 9 mg: 2 caps/day = 30 MME/day; 27 mg: 3 caps/day = 135 MME/day

Some strengths blockedCertain higher Xtampza ER strengths (e.g., 36 mg in some columns) are listed as 0*** in initial columns

Certified OTPs must dispense and use methadone in oral form only and follow federal opioid treatment standards (42 CFR 8.12)

Regulatory exceptionsExceptions permit inpatient use for non‑addiction admissions and emergency periods up to 3 days per 21 CFR provisions

Xtampza ER / ER opioids — definition

ER opioid definitionExtended‑release opioid formulations (including Xtampza ER) are indicated for severe, persistent pain requiring extended daily opioid therapy and should be reserved when alternatives are ineffective, not tolerated, or inadequate

Not for PRN useER opioids are not indicated for as‑needed (prn) analgesia

Clinical reservationER opioids should be used only when non‑opioid analgesics or immediate‑release opioids are inadequate

Chronic pain — definition and monitoring

Chronic pain definitionPain typically lasting greater than 3 months; authorization criteria include ongoing opioid use, regular monitoring, and reassessment of pain and function

Monitoring requirementsReassess pain within first month after initial prescription or dose increase and every 3 months thereafter

Dose safetyLowest effective dose should be used; evaluate patient opioid history to ensure safe dosing

Duration of Approval (DOA)

DOA for cancer/sickle cell/terminal/palliativeDuration of Approval (DOA): 12 months for pain associated with cancer, sickle cell disease, a terminal condition, or hospice/palliative care

DOA for chronic painDOA: 6 months for chronic pain indications

DOA determines authorization lengthIndication documented in the request governs assignment of DOA