CurrentsanfranciscohealthplanPolicy N/A

Controlled substances opioid therapy agreement — Coverage criteria

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Defines expectations, responsibilities, monitoring, and grounds for discontinuation when prescribing controlled opioid analgesics to San Francisco Health Plan patients in primary care; affects patients receiving scheduled (controlled) opioid medications and their prescribing providers.

Policy Summary

Payersanfranciscohealthplan

PolicyControlled substances opioid therapy agreement — Coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest routine refill 7 days in advance during regular business hours for provider review and authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualagreement review frequency

≥1/yrurine drug screening

7 daysrefill notice

no replacementreplacement policy

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CurrentsanfranciscohealthplanPolicy N/A

Controlled substances opioid therapy agreement — Coverage criteria

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Policy Summary

Payersanfranciscohealthplan

PolicyControlled substances opioid therapy agreement — Coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest routine refill 7 days in advance during regular business hours for provider review and authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualagreement review frequency

≥1/yrurine drug screening

7 daysrefill notice

no replacementreplacement policy

Coverage Criteria for Continued Opioid Prescribing

Conditions for ongoing opioid prescribing

Continued prescribing is contingent on meeting ALL of the following patient responsibilities and provider monitoring expectations:

Patient responsibilities: Patient must take medications only as prescribed; participate in developing and following the treatment plan (which may include nonpharmacologic therapies such as group classes, specialist referral, acupuncture, massage, mindfulness, and diagnostic tests); bring medications to visits for possible pill counts when requested; attend scheduled appointments or notify the clinic to reschedule; disclose prior or concurrent prescriptions for controlled substances and any personal or family history of substance use disorder; inform the provider of pregnancy or plans for pregnancy when applicable; store medications securely (lost, stolen, or damaged medications will not be replaced); request routine refills at least 7 days in advance during regular business hours; and consent to urine drug screening at least annually or more often as requested.

Derived from patient obligations, refill timing, and testing frequency

Provider responsibilities: Provider must assess pain and functioning, prepare a safe treatment plan consistent with controlled substance laws, include multimodal/nonopioid therapies as appropriate, monitor implementation (including urine drug testing and pharmacy record review as required by California law, and pill counts when requested), reassess and review the agreement at least annually or sooner if the patient changes providers or violates the agreement, and discontinue or refer for addiction treatment if misuse, diversion, unsafe concomitant medication use, or harm is identified.

Derived from provider monitoring, documentation, and grounds for discontinuation

Medications will be discontinued if any of the following occur: the medication(s) do not help the patient or cause harm; the provider determines the patient is not a candidate to continue the medication; the patient obtains controlled substances elsewhere without prior approval from the prescribing provider; the patient diverts, sells, or otherwise gives prescribed medications to others; the patient forges or alters prescriptions; the patient’s health worsens such that continuation would threaten safety; urine drug testing shows use of illicit drugs or controlled substances not prescribed to the patient; urine drug testing does not detect the prescribed medication; the patient fails to complete recommended medical procedures or evaluations; the patient behaves disrespectfully, aggressively, or abusively toward staff; or the patient refuses to stop or begins taking a medication that the provider considers unsafe to use concomitantly with the prescribed controlled substance.

Continued prescribing is not appropriate and will be discontinued when the medication does not benefit the patient or causes harm. If the provider judges that ongoing therapy is unsafe or ineffective, they will stop prescribing and may offer referral for addiction treatment when appropriate (for example, buprenorphine treatment or referral to a methadone program).

Provider Responsibilities and Operational Rules

Prior Authorization

Refill timing and authorization

Routine refill requests for controlled (scheduled) medications must be requested during regular business hours and submitted with at least 7 days advance notice to allow provider review and authorization; refill requests are not processed on weekends, holidays, or by on‑call providers.

Requests must be made at least 7 days before the medication runs out.
Refill requests are accepted only during regular business hours; not processed on weekends, holidays, or by on‑call staff.

Step Therapy

Expect and document multimodal (non‑opioid/non‑pharmacologic) care

The treatment plan is expected to be multimodal and may include non‑opioid medications and non‑pharmacologic therapies (for example group classes, specialty referral, acupuncture, massage, mindfulness, behavioral therapies) as part of comprehensive care before or alongside controlled‑substance therapy.

Patient and provider will develop and follow a plan that may include nonpharmacologic options.
Engagement with these therapies is an expectation of ongoing treatment.

Documentation Required

Review pharmacy records and document monitoring

Providers must review pharmacy records as required by California law and document the treatment plan, including the agreed dosing schedule and monitoring activities (e.g., urine drug testing and pill counts when requested).

Document agreed‑upon dosing schedule and monitoring frequency.
Perform and record pharmacy record checks and selective pill counts when requested.
Obtain consent and document urine drug screening at least annually or more often as indicated.

Denial Risk

Grounds for discontinuation of controlled substances

Controlled‑substance prescriptions may be discontinued for specified reasons including diversion, obtaining controlled substances elsewhere without provider approval, forging or altering prescriptions, urine drug screen showing illicit drugs or absence of prescribed drugs, nonadherence to recommended procedures, unsafe concomitant medication use, or when medications do not benefit or harm the patient.

Patient diverting, selling, or otherwise distributing prescribed medications.
Patient obtains controlled substances from other providers without prior authorization.
Patient forges or alters prescriptions.
Urine drug screen positive for illicit substances or negative for prescribed medications.
Patient refuses or fails to complete recommended medical procedures or monitoring.
Worsening health or unsafe concomitant medication use leading the provider to conclude continuation is unsafe.
Medications cause harm or provide no benefit — treatment may be stopped and referral for addiction treatment offered if dependence develops.

Participation and Conservative Treatment Requirements

Participation as agreed with provider

Participation as agreed with the provider is required and includes at minimum ALL of the following:

Engagement in agreed treatment plan: Patient agrees to engage with the jointly developed treatment plan, which may include nonpharmacologic therapies (e.g., group classes, specialist referral, acupuncture, massage, mindfulness) and diagnostic testing as indicated.

From conservative treatment expectations

Appointment and communication expectations: Patient will attend scheduled appointments or contact the clinic to reschedule and will notify the provider in advance (at least 7 days) for routine refill requests during regular business hours.7 days notice for routine refills

Reflects refill timing and scheduling requirements

Medication management and safety: Patient will take medications only as prescribed, will not take other opioid or controlled medications (including benzodiazepines or sedative-hypnotics) without provider approval, will store medications securely, and understands lost, stolen, or damaged medications will not be replaced.

Derived from medication and safety instructions

Monitoring and testing participation: Patient consents to periodic monitoring including bringing medications for pill counts, urine drug screening at least once per year (and more frequently if requested), and allowing pharmacy record checks as required by law.urine drug screen >=1/yr

Reflects minimum urine drug testing frequency and record review

Disclosure responsibilities: Patient will disclose prior or concurrent prescriptions for controlled substances from other providers and any history of substance use or addiction in themselves or family members; will inform the provider of pregnancy or plans for pregnancy when applicable.

From patient information reporting requirements

Background

Chronic pain is a complex condition that typically requires a multimodal treatment approach focused on improving function and quality of life. Nonpharmacologic and non-opioid therapies (for example, acupuncture, massage, behavioral therapies, and specialty referrals) are expected components of a comprehensive plan and participation in agreed treatments is required. Opioid analgesics may be used when clinically appropriate to help restore function, but they do not eliminate pain and carry risks including overdose, dependence, and adverse effects; providers must therefore monitor treatment closely and reassess the treatment agreement at least annually.

Controlled substances opioid therapy agreement — Coverage criteria

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Controlled substances opioid therapy agreement — Coverage criteria

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Coverage Criteria for Continued Opioid Prescribing

Provider Responsibilities and Operational Rules

Participation and Conservative Treatment Requirements

Imaging When Clinically Indicated

Definitions

Background