Long-acting Opioid Prior Authorization Criteria
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Criteria and prior authorization requirements for coverage of long-acting opioid-containing products for Select Health of South Carolina members, including preferred and non-preferred products and clinical requirements for initial and reauthorization approvals.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial and Reauthorization Criteria
Covered when ALL of the following are met:
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Members currently taking buprenorphine-containing products for opioid treatment are listed under the policy's exclusion criteria and are not considered under the long-acting opioid coverage pathway described here. Prior authorization is required for long-acting opioid-containing products per Select Health of South Carolina Long Acting (LA) Opioid criteria; prescribers must submit required documentation and meet the policy criteria for coverage consideration.
Provider Actions & Authorization Requirements
Prior authorization required for long‑acting opioids
Prior authorization is required for all long‑acting opioid‑containing products under the Select Health of South Carolina Long‑Acting (LA) Opioid criteria; prescriber considerations and required documentation must be submitted with the request.
Fail two formulary LA opioids for non‑formulary requests
For requests for non‑formulary long‑acting opioid products the member must have tried and failed two formulary long‑acting opioid drugs unless a Medical Director or clinical reviewer overrides the requirement.
Required clinical documentation to support PA
Submit clinical documentation including: a pain treatment plan and goals consistent with the SC LLR Joint Revised Pain Management Guidelines (updated on reauthorization); a functional pain scale with comparison to baseline (the functional pain scale must be included); evidence of prior short‑acting opioid use for ≥3 months when applicable; and prescriber attestations (Opioid Treatment Agreement on file, SCRIPTS monitoring checked, and documented discussion of benefits/harms and naloxone education when indicated).
- Pain treatment plan and goals consistent with SC LLR Joint Revised Pain Management Guidelines
- Functional pain scale with baseline comparison (must be included)
- Opioid Treatment Agreement signed by patient and prescriber on file
- Documentation of SCRIPTS monitoring check and discussion of benefits/harms (including CNS co‑ingestion risks)
- Naloxone discussion/consideration if patient is high‑risk per CDC guidance
Requests not meeting criteria will be referred for clinical review
If the request does not meet all stated criteria it will be referred to a clinical reviewer for a medical necessity determination and possible denial without additional clinical justification.
Initial Therapy Criteria
Initial therapy requirements
Initial therapy coverage criteria
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Continuation / Reauthorization Criteria
Reauthorization duration
Approval duration pattern on reauthorization
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Step Therapy Requirements
| Required steps before approval of non‑formulary long‑acting (LA) opioid products |
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| Patient meets criteria 1–6 in the policy (diagnosis of chronic pain requiring around‑the‑clock opioid therapy after inadequate relief from short‑acting opioids; documented pain treatment plan and goals; trial of or contraindication to non‑opioid therapy; inclusion of non‑pharmacologic modalities; functional pain scale documented; prescriber attestations including opioid treatment agreement, SCRIPTS check, benefits/harms discussion and naloxone discussion if high‑risk). |
| Patient must have tried and failed two (2) formulary long‑acting opioid drugs prior to approval of a non‑formulary LA opioid product. |
| Medical Director or clinical reviewer may override the step requirement when, in his/her professional judgment, the requested item is medically necessary. |
Definitions & Medically Accepted Indications
Background
This policy governs use of long-acting opioid formulations for patients with chronic pain who require around-the-clock opioid therapy after inadequate relief from short-acting opioids used for at least three months. It emphasizes a multimodal approach to pain management, including incorporation of non-opioid pharmacologic therapies and non-pharmacologic modalities as part of the treatment plan, ongoing functional assessment using a functional pain scale, and documented prescriber attestations such as an Opioid Treatment Agreement and prescription monitoring checks.
For initial and reauthorization approvals, coverage is contingent on a documented pain treatment plan and goals consistent with the SC LLR Joint Revised Pain Management Guidelines, inclusion of non-opioid treatments or a documented contraindication to them, and prescriber documentation of monitoring and risk mitigation steps. Prior authorization is required and non-formulary long-acting opioid products generally require failure of two formulary long-acting opioid agents unless overridden by a Medical Director or clinical reviewer.
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