Short-acting opioid prior authorization (Select Health of South Carolina)
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Criteria governing prior authorization for short-acting opioid prescriptions for Select Health of South Carolina members, including initial and reauthorization requirements, age limits, exclusions, and prescriber considerations. Affects prescribers and pharmacy authorization staff.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Authorization
Covered when ALL of the following are met for initial authorization:
Reauthorization
Reauthorization requires meeting ALL of the following:
Medical Director/clinical reviewer may override if medically necessary.
Exemptions and authorization durations
Exemptions and special-authority durations:
Members who are currently receiving treatment with buprenorphine-containing products are excluded from this prior authorization policy. Coverage rules and limits in this policy do not apply to members whose opioid therapy is managed with buprenorphine-containing medications.
Initial Therapy Criteria
Initial therapy
Initial authorization requirements for short-acting opioids:
Provider Actions & Requirements
Prior authorization required when thresholds or special conditions met
Prior authorization is required for short-acting opioid prescriptions that exceed 90 MME/day, exceed a 5-day supply, constitute more than one opioid prescription in a 30-day period, or are non-preferred without documented trials of three formulary alternatives. Naïve members are those without a short-acting opioid fill in the prior 60 days; exemptions apply for participating hematologists, oncologists, and hospice providers and for certain diagnoses (sickle cell disease, cancer, palliative/hospice care) with specified authorization durations.
- Applies when short-acting opioids are >90 MME or >5 days
- Applies when more than one opioid prescription is needed within 30 days
- Non-preferred opioids require prior authorization unless three formulary alternatives are documented as tried and failed
- Exempt prescribers: participating hematologists, oncologists, hospice providers
Three formulary alternatives must be tried and failed
For requests for non-preferred short-acting opioids, the prescriber must document that three formulary alternatives have been tried and failed before coverage will be approved.
- Documentation must show trials (and failures) of three formulary alternatives prior to approval
Provide required clinical documentation and reauthorization details
Prescriber must supply clinical documentation including: diagnosis showing pain uncontrolled by non-opioid medications; evidence the patient is using or has been prescribed a separate non-opioid (e.g., acetaminophen or NSAID) or a medical justification why non-opioid therapy cannot be used; and documentation supporting medical necessity for dosing above 90 MME and/or a supply greater than 5 days (for example, acute injury or surgical procedure). For reauthorization, include dose titration down or justification for continued high dose, a treatment plan to reduce dose or rationale why not recommended, and documentation of patient response (decreased pain, improved function or quality of life).
- Initial requests: diagnosis for pain uncontrolled by non-opioid meds; trial or prescription of a non-opioid OR reason non-opioid cannot be used; justification for >90 MME and/or >5-day supply (e.g., acute injury, surgery)
- Reauthorization: evidence dose is titrated down OR explanation for continued >90 MME/>5 days plus a treatment plan to reduce dose and documentation of response
Attest to checking S.C. SCRIPTS per state law
Prescriber must attest that the S.C. SCRIPTS prescription monitoring database was checked prior to issuing the controlled substance prescription, in accordance with S.C. Code §44-53-1645; this attestation is required for both initial authorization and reauthorization requests.
- Attestation of S.C. SCRIPTS check is required before provision of a controlled substance prescription for initial and reauthorization requests
Conditions that will trigger denial
Requests will be subject to denial if they exceed >90 MME/day or a >5-day supply, if more than one opioid prescription is requested within 30 days without authorization, or if a non-preferred opioid is requested without documentation that three formulary alternatives were tried and failed. Missing required clinical documentation (diagnosis, non-opioid trial or justification, medical necessity for high dose/longer supply) or failure to attest to the SCRIPTS check may also trigger denial.
- Triggers: >90 MME/day or >5-day supply
- More than one opioid prescription in 30 days without authorization
- Non-preferred opioid requests without documentation of three tried-and-failed formulary alternatives
- Missing required clinical documentation (diagnosis, non-opioid trial/justification, medical necessity for exceedance)
- Failure to attest to S.C. SCRIPTS check
Dose / Duration Thresholds
Step Therapy / Formulary Alternatives
| Requirement | Details |
|---|---|
| Step therapy requirement | For non-preferred opioid requests, prescribers must demonstrate that three formulary alternatives have been tried and failed before coverage is approved. |
Definitions
Background
This policy establishes prior authorization requirements for short-acting opioid prescriptions intended for opioid‑naïve members, with the objective of limiting high-dose exposure (>90 MME/day) and prolonged initial therapy (>5 days). It applies when initial prescriptions exceed 90 morphine milligram equivalents (MME), when the supply is for more than 5 days, when more than one opioid prescription is clinically necessary within 30 days, or when a non-preferred opioid is requested without documentation of trials of three formulary alternatives. The policy defines a naïve member as one who has not filled a short-acting opioid prescription in the prior 60 days and remains classified as naïve while enrolled in the plan.
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