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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsTennCare Opioid Coverage Prior Auth | OpenPayer
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    CurrentTennessee Department of Finance and Administration — Division of TennCarePolicy N/A

    Opioid Criteria - Acute, Chronic, and Exceptions

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    This policy governs TennCare coverage, quantity limits, and prior authorization requirements for acute, chronic, and extended opioid use. It applies to TennCare members and requires opioid prescriptions to be issued by a provider with a Tennessee Medicaid Provider ID.

    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    PolicyOpioid Criteria - Acute, Chronic, and Exceptions
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSeptember 1, 2023
    Next Review DateN/A
    Key ActionSubmit prior authorization for chronic opioid use and for additional acute or extended-use opioid treatment when applicable.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    5 days

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    First-fill short-acting opioid supply without prior authorization
    60 MME/dayStandard maximum opioid dosage
    15 days/180 daysStandard acute opioid coverage limit
    45 days/90 daysException quantity for burn, sickle cell, and long-term-care requests
    180 daysChronic opioid approval duration

    Opioid Coverage Criteria

    Acute Opioid Use

    Covered when ALL applicable criteria are met. Acute opioid coverage is limited to a maximum of 15 days in a 180-day period and 60 MME per day. The first fill in a 180-day period is limited to 5 days of a short-acting opioid without prior authorization; up to an additional 10 days requires prior authorization.

    ALL of the following

    • Diagnosis of moderate-severe pain.
    • The prescriber assessed the member using a Screening, Brief Intervention, and Referral to Treatment (SBIRT) Questionnaire (e.g., SBIRT Survey) for members older than 18 years, or an adolescent SBIRT Questionnaire (e.g., SBIRT CRAFFT Survey) for members ages 11 through 18.
    • The patient is not currently undergoing active treatment for opioid addiction.

    • Female members ages 14 through 44 meet ONE of the following:

      • The member is not pregnant and is using contraception, such as a barrier method, oral contraceptive, or rhythm method.
      • The member has an intrauterine device (IUD) or implant.
      • The member has a history of hysterectomy, tubal ligation, or endometrial ablation.
    • Concomitant use of benzodiazepines and opioids is approved only under the care of, or referral to, a mental health provider.

    Chronic Opioid Use — 180-Day Approval

    Chronic opioid use is approved for 180 days when the member meets at least one qualifying eligibility pathway and ALL applicable clinical requirements.

    ALL of the following

    • ONE qualifying eligibility pathway:

      • The member is an established TennCare member and has received opioids for 90 days or more, according to TennCare claims, during the last 180 days.
      • The member is newly eligible for TennCare, or TennCare became primary within the last 180 days, and has established prescription opioid use for 90 days or more during the last 180 days. The prescriber must submit patient records, including diagnosis, treatment plan, and prescription records.
      • The member has a diagnosis of active cancer undergoing active or palliative cancer treatment, or is receiving hospice and palliative care (hospice or end-of-life care). A signed and faxed physician attestation with supporting documentation and a patient-specific clinical treatment plan is required, affirming the applicable treatment.

    Burn, Corrosion, and Sickle Cell Exceptions

    Extended opioid use for pain attributed to sickle cell disorder or pain resulting from severe burn or corrosion recovery is approved for up to a 45-day quantity every 90 days, not to exceed 60 MME per day, when ALL criteria are met.

    ALL of the following

    • A signed and faxed attestation, including supporting documentation and a patient-specific clinical action plan, indicates that the request is for treatment of acute pain due to sickle cell disorder (SCD) or pain resulting from burn or corrosion recovery requiring referral to a burn center, unless the member is in a rural area with limited access to a burn recovery center.

    • Moderate-severe pain is documented by ALL of the following:

      • Documentation shows that non-opioid analgesic treatment was nonresponsive or inadequately responsive, such as NSAIDs, acetaminophen (APAP), gabapentin, lidocaine patch, or muscle relaxers.
      • The pain significantly impairs physical functioning, such as activities of daily living, sleep, or work.

    Long-Term-Care Exception

    Extended opioid use for a member residing in a Medicaid-certified nursing facility is approved for up to a 45-day quantity every 90 days, not to exceed 60 MME per day, when ALL criteria are met.

    ALL of the following

    • A signed and faxed attestation, including supporting documentation and a patient-specific clinical action plan, indicates that the request is for treatment of a patient residing in a Medicaid-certified nursing facility.
    • A copy of the patient's pre-admission evaluation form (PAE) is submitted with the request.

    • Moderate-severe pain is documented by ALL of the following:

      • Documentation shows that non-opioid analgesic treatment was nonresponsive or inadequately responsive, such as NSAIDs, acetaminophen (APAP), gabapentin, lidocaine patch, or muscle relaxers.
      • The pain significantly impairs physical functioning, such as activities of daily living, sleep, or work.

    Opioid coverage is excluded for a patient who is currently undergoing active treatment for opioid addiction.

    For female members ages 14 through 44, the member must not be pregnant and must be using contraception, such as a barrier method, oral contraceptive, or rhythm method; have an intrauterine device (IUD) or implant; or have a history of hysterectomy, tubal ligation, or endometrial ablation. Providers must counsel women of childbearing age about the risks of becoming pregnant while receiving opioids, including Neonatal Abstinence Syndrome, and should offer access to effective contraceptive services when necessary.

    Dosage, Duration, and Authorization Parameters

    Standard opioid dosage
    LimitMaximum 60 MME per day
    Applies toOpioid agents
    Exception pathwayBurn, corrosion, sickle cell, and long-term-care exceptions also must not exceed 60 MME per day
    Standard acute coverage period
    Coverage periodUp to 15 days in a 180-day period
    First fillLimited to a 5-day quantity of a short-acting opioid
    Additional supplyUp to an additional 10-day quantity after the first fill, with prior authorization

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    Acute Opioid Prior Authorization

    For acute opioid treatment, the first fill in a 180-day period is limited to a 5-day supply of a short-acting opioid at no more than 60 MME/day without PA. After that first fill, additional acute treatment requires PA and may be approved for up to 10 additional days, not exceeding 15 total days or 60 MME/day in the 180-day period.

    • First fill: maximum 5-day quantity.
    • Additional treatment: PA required; maximum 10-day quantity.
    • Overall acute limit: 15 days per 180 days and 60 MME/day.
    Prior Authorization

    Chronic Opioid Prior Authorization

    Chronic opioid use requires PA approval for 180 days. Submit the applicable eligibility pathway and demonstrate the required clinical monitoring and safety criteria before requesting authorization.

    • Eligible pathways include at least 90 days of opioid use in the previous 180 days for an established TennCare member, qualifying established opioid use for a newly eligible member or member for whom TennCare recently became primary, active cancer treatment, or hospice/palliative care.

    Policy Rationale and Scope

    This policy limits opioid exposure by restricting the initial short-acting opioid fill and requiring prior authorization for additional acute treatment, chronic therapy, and extended-use exceptions. Coverage focuses on moderate-to-severe pain, functional impairment where applicable, inadequate response to non-opioid analgesics for exception pathways, substance-use screening, controlled-substance monitoring, pregnancy-related safety, and coordinated management of concomitant benzodiazepine use. Standard acute treatment is limited to 15 days per 180 days at no more than 60 MME per day; chronic therapy and qualifying exceptions require authorization and supporting clinical documentation.

    Key Terms

    SBIRT
    Full termScreening, Brief Intervention, and Referral to Treatment
    AdultsPatients older than 18 use an SBIRT Survey
    AdolescentsPatients ages 11 through 18 use an adolescent SBIRT or CRAFFT Survey
    MME/day
    MeaningMorphine milligram equivalents per day
    Policy useUsed as the opioid dosage limit
    Standard ceilingMaximum 60 MME per day

    Initial and Additional Acute Therapy

    Initial Acute Opioid Fill

    The first opioid fill in a 180-day period is available without prior authorization when all limits are met.

    First fill

    • The prescription is for a short-acting opioid.
    • The quantity does not exceed 5 days.5-day quantity
    • The dosage does not exceed 60 MME per day.Maximum 60 MME/day

    Additional Acute Opioid Treatment

    Additional acute opioid treatment after the first fill requires prior authorization.

    Continuation and Renewal Criteria

    Chronic Opioid Continuation

    Continuation of chronic opioid therapy requires renewal authorization and continued satisfaction of the chronic-use criteria.

    Chronic continuation

    • Qualifying chronic-use pathway

      • The member is an established TennCare member with 90 or more opioid days in the last 180 days.
      • The member is newly eligible for TennCare, or TennCare became primary within the last 180 days, with established opioid use for 90 or more days in the last 180 days.
      • The member has active cancer receiving active or palliative cancer treatment.
      • The member is receiving hospice or palliative care for a serious and/or life-threatening illness.

    Non-Opioid Treatment Trial

    StepRequirementDocumentation / examples
    1For burn/corrosion, sickle cell, and long-term-care exception requests, document an inadequate or non-responsive response to non-opioid analgesic treatment before opioid approval.Document treatment response. Examples include NSAIDs, acetaminophen (APAP), gabapentin, lidocaine patches, and muscle relaxers.

    Opioid Quantity and Dose Limits

    Opioid agents
    Standard limitUp to 15 days in a 180-day period
    First fillLimited to 5 days
    Subsequent supplyLimited to an additional 10 days with prior authorization
    Opioid agents
    Dosage limitMaximum 60 MME per day
    Standard acute useApplies to opioid coverage within the 15-day-per-180-day limit
    Extended exceptionsBurn, corrosion, sickle cell, and long-term-care exceptions also must not exceed 60 MME per day
    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    PolicyOpioid Criteria - Acute, Chronic, and Exceptions
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSeptember 1, 2023
    Next Review DateN/A
    Key ActionSubmit prior authorization for chronic opioid use and for additional acute or extended-use opioid treatment when applicable.
    SourceLink
    On This Page
    Opioid Coverage CriteriaDosage, Duration, and Authorization ParametersAuthorization, Documentation, and Denial RisksPolicy Rationale and ScopeKey TermsInitial and Additional Acute TherapyContinuation and Renewal CriteriaNon-Opioid Treatment TrialOpioid Quantity and Dose Limits
    A signed and faxed physician attestation with supporting documentation affirms that the patient is receiving hospice and palliative care for a serious and/or life-threatening illness (hospice or end-of-life care).
  1. Diagnosis of moderate-severe pain that significantly impairs physical functioning, such as activities of daily living, sleep, or work.
  2. The prescriber checked the Tennessee Controlled Substance Database within the previous 7 days.
  3. The prescriber assessed the member using a SBIRT Questionnaire for members older than 18 years, or an adolescent SBIRT Questionnaire (e.g., SBIRT CRAFFT Survey) for members ages 11 through 18.
  4. The patient is not currently undergoing active treatment for opioid addiction.

  5. Female members ages 14 through 44 meet ONE of the following:

    • The member is not pregnant and is using contraception, such as a barrier method, oral contraceptive, or rhythm method.
    • The member has an intrauterine device (IUD) or implant.
    • The member has a history of hysterectomy, tubal ligation, or endometrial ablation.
  6. A pain agreement is completed for all prior-authorization-required agents. For patients younger than 18 years, the agreement may be completed by a parent or legal guardian.
  7. Concomitant use of benzodiazepines and opioids is approved only under the care of, or referral to, a mental health provider.
    8. The prescribing physician checked the Tennessee Controlled Substance Monitoring Database within the last 7 days.
  8. The prescriber assessed the member using a SBIRT Questionnaire for members older than 18 years, or an adolescent SBIRT Questionnaire (e.g., SBIRT CRAFFT Survey) for members ages 11 through 18.
  9. The patient is not currently undergoing active treatment for opioid addiction.

  10. Female members ages 14 through 44 meet ONE of the following:

    • The member is not pregnant and is using contraception, such as a barrier method, oral contraceptive, or rhythm method.
    • The member has an intrauterine device (IUD) or implant.
    • The member has a history of hysterectomy, tubal ligation, or endometrial ablation.
  11. A pain agreement is completed for all prior-authorization-required agents. For patients younger than 18 years, the agreement may be completed by a parent or legal guardian.
  12. Concomitant use of benzodiazepines and opioids is approved only under the care of, or referral to, a mental health provider.
  13. The prescriber assessed the member using a SBIRT Questionnaire for members older than 18 years, or an adolescent SBIRT Questionnaire (e.g., SBIRT CRAFFT Survey) for members ages 11 through 18.
  14. The patient is not currently undergoing active treatment for opioid addiction.

  15. Female members ages 14 through 44 meet ONE of the following:

    • The member is not pregnant and is using contraception, such as a barrier method, oral contraceptive, or rhythm method.
    • The member has an intrauterine device (IUD) or implant.
    • The member has a history of hysterectomy, tubal ligation, or endometrial ablation.
  16. A pain agreement is completed for all prior-authorization-required agents. For patients younger than 18 years, the agreement may be completed by a parent or legal guardian.
  17. Concomitant use of benzodiazepines and opioids is approved only under the care of, or referral to, a mental health provider.
    18. First-fill supply
    Initial quantity5-day quantity
    Medication typeShort-acting opioid
    Prior authorizationAvailable without prior authorization when the supply and dosage limits are met
    Post-first-fill acute supply
    Additional quantityUp to an additional 10-day quantity
    Review periodIn each 180-day period
    Prior authorizationRequired after the first-fill prescription
    Chronic-use history
    Utilization history90 days or more of opioids in the last 180 days
    Claims basisOpioid days are measured per TennCare claims
    Approval durationChronic opioid approval duration is 180 days
    Extended exception quantity
    Exception quantityUp to 45 days every 90 days
    Applicable requestsBurn, corrosion, sickle cell, and Medicaid-certified nursing-facility exceptions
    Dosage ceilingNo more than 60 MME per day
    Controlled-substance database review
    Review requiredThe Tennessee Controlled Substance Database must be checked within the previous 7 days
    Applies toChronic opioid requests
    DocumentationThe database check must be documented with the chronic-use request
  18. Check the Tennessee Controlled Substance Monitoring Database within the previous 7 days.
  19. Complete the applicable SBIRT assessment and document moderate-severe pain with significant functional impairment.
  20. A pain agreement is required for all PA-required agents.
    21. Prior Authorization

    Extended-Use Exception Authorization

    Requests exceeding the standard acute limits may qualify for an extended-use clinical exception. The request must identify the applicable exception category and include the required attestation, clinical support, and patient-specific action plan.

    • Burn or corrosion recovery requiring referral to a burn center, unless the member lives in a rural area with limited access to a burn recovery center, or pain attributed to sickle cell disorder: up to a 45-day quantity every 90 days, not exceeding 60 MME/day.
    • Medicaid-certified nursing-facility residents: up to a 45-day quantity every 90 days, not exceeding 60 MME/day.
    • Nursing-facility requests must include the patient's pre-admission evaluation form (PAE).
    • Burn/corrosion, sickle-cell, and nursing-facility requests require a signed and faxed attestation with supporting documentation and a patient-specific clinical action plan.
    Documentation Required

    Clinical Safety Documentation

    Document the clinical and safety facts supporting opioid treatment. Approval requires moderate-severe pain, appropriate risk screening, and compliance with addiction-treatment, pregnancy-risk, and benzodiazepine safeguards.

    • Document pain and significant impairment of physical functioning, such as effects on activities of daily living, sleep, or work.
    • Complete an adult SBIRT assessment for patients over 18 or an adolescent SBIRT/CRAFFT assessment for patients ages 11–18.
    • Do not approve when the patient is currently undergoing active treatment for opioid addiction.
    • For women of childbearing age (14–44), document that the patient is not pregnant and meets the applicable contraception, IUD/implant, hysterectomy, tubal ligation, or endometrial-ablation requirement.
    • Concomitant benzodiazepine and opioid use is approved only under the care of, or referral to, a mental health provider.
    • Counsel women of childbearing age about pregnancy risks, including Neonatal Abstinence Syndrome, and offer access to effective contraceptive services when necessary.
    Documentation Required

    Chronic-Use Records and Agreement

    For chronic-use PA, retain records establishing eligibility and the ongoing treatment plan. A signed pain agreement is required for every PA-required agent, including when completed by a parent or legal guardian for a patient younger than 18.

    • Submit patient records for newly eligible members or members for whom TennCare recently became primary when established prescription opioid use is documented for at least 90 days in the previous 180 days.
    • Records must include, at minimum, the diagnosis, treatment plan, and prescription records.
    • For active cancer treatment, submit a signed and faxed physician attestation with supporting documentation and a patient-specific clinical treatment plan.
    • For hospice or palliative care, submit a signed and faxed physician attestation with supporting documentation confirming care for a serious and/or life-threatening illness.
    • Use the Opioid and Controlled Substance Agreement: https://www.optumrx.com/content/dam/openenrollment/pdfs/Tenncare/presciber/prior-authorization-forms/Patient%20Medication%20Management%20Agreement.pdf
    Documentation Required

    Exception Request Documentation

    Exception requests are incomplete without the required attestation and supporting clinical records. Submit documentation that connects the qualifying exception to the requested opioid treatment and identifies a patient-specific action plan.

    • Signed and faxed physician or prescriber attestation.
    • Supporting medical documentation identifying the qualifying condition or care setting.
    • Patient-specific clinical action plan.
    • For nursing-facility requests, a copy of the patient's PAE.
    • For burn/corrosion or sickle-cell requests, documentation that the request concerns acute pain from the qualifying condition and, when applicable, the need for burn-center referral.
    • Document nonresponse or inadequate response to non-opioid analgesics, functional impairment, recent controlled-substance-database review, SBIRT assessment, pain agreement, and applicable pregnancy and addiction-treatment safeguards.
    Documentation Required

    Pregnancy-Risk Counseling

    Counsel women of childbearing age (14–44) about the risks of becoming pregnant while receiving opioids, including Neonatal Abstinence Syndrome. Offer access to effective contraceptive services when necessary and document the applicable safety status.

    • Document that the patient is not pregnant.
    • Document contraception, such as a barrier method, oral contraceptive, or rhythm method; an IUD or implant; or a history of hysterectomy, tubal ligation, or endometrial ablation.
    Denial Risk

    Acute Quantity or Dose Exceeds Limit

    Acute requests above the standard quantity, duration, or dose limits require PA and may be denied when the request exceeds the permitted supply or dosage.

    • Without PA, the first fill is limited to 5 days of a short-acting opioid and 60 MME/day.
    • With PA, additional acute treatment is limited to 10 days and 60 MME/day.
    • Do not request more than 15 total days of acute opioid treatment in a 180-day period unless an applicable extended-use exception is requested.
    Denial Risk

    Chronic-Use Criteria Not Met

    Chronic-use PA may be denied when the member does not meet an eligibility pathway or the submission lacks required clinical evidence. Confirm the 180-day approval pathway and provide complete records before submission.

    • Document at least 90 days of opioid use in the previous 180 days when relying on established use.
    • For newly eligible members or members for whom TennCare recently became primary, submit diagnosis, treatment plan, and prescription records supporting established use.
    • Document moderate-severe pain that significantly impairs physical functioning.
    • Document the controlled-substance-database check within the previous 7 days and the appropriate SBIRT assessment.
    • Include the required pain agreement.
    Denial Risk

    Exception Documentation Incomplete

    An exception request may be denied or returned when required attestations, records, clinical findings, or the patient-specific action plan are missing or insufficient.

    • Submit the signed and faxed attestation and supporting documentation.
    • Include the patient-specific clinical action plan and documentation of the qualifying burn/corrosion, sickle-cell, or nursing-facility circumstance.
    • Include the PAE for Medicaid-certified nursing-facility requests.
    • Document inadequate response to non-opioid treatment and significant functional impairment.
    • Include the recent Tennessee Controlled Substance Monitoring Database review, SBIRT assessment, pain agreement, and applicable safety documentation.
    Denial Risk

    Safety Criteria Not Met

    Requests may be denied when required safety criteria are not documented or are contradicted by the clinical record. Apply the addiction-treatment, pregnancy, contraception, SBIRT, and benzodiazepine safeguards to acute, chronic, and exception requests.

    • Do not approve treatment for a patient currently undergoing active treatment for opioid addiction.
    • For women ages 14–44, document nonpregnancy and the applicable contraception, IUD/implant, hysterectomy, tubal ligation, or endometrial-ablation status.
    • Document required SBIRT or adolescent SBIRT/CRAFFT assessment.
    • Counsel about pregnancy-related opioid risks, including Neonatal Abstinence Syndrome, and offer effective contraceptive services when necessary.
    • Concomitant benzodiazepines and opioids require care by or referral to a mental health provider.
    Billing Rule

    Prescriber Eligibility

    All opioid agents must be prescribed by a provider with a Tennessee Medicaid Provider ID. Requests that do not identify an eligible prescriber may not be authorized.

    • Confirm the prescriber has a Tennessee Medicaid Provider ID before submitting acute, chronic, or exception PA.
    • This requirement applies to standard opioid PA and extended-use exception requests.
    Hospice and palliative care
    DefinitionHospice or end-of-life care
    Clinical contextCare for a serious and/or life-threatening illness
    Coverage pathwayA qualifying pathway for chronic opioid approval

    Additional acute supply

    • The member has moderate-to-severe pain.
    • The prescriber completed the applicable adult or adolescent SBIRT assessment.
    • The patient is not currently undergoing active treatment for opioid addiction.

    • Pregnancy and contraception

      • The female member ages 14 through 44 is not pregnant and is using contraception.
      • The member has an intrauterine device or implant.
      • The member has a history of hysterectomy, tubal ligation, or endometrial ablation.
    • Concomitant benzodiazepine and opioid use is managed under the care of, or referral to, a mental health provider.
  21. The member continues to have moderate-to-severe pain that significantly impairs physical functioning, such as activities of daily living, sleep, or work.
  22. The prescriber has current Tennessee Controlled Substance Database review within the previous 7 days and has completed the applicable adult or adolescent SBIRT assessment.
  23. The patient is not currently undergoing active treatment for opioid addiction.

  24. Pregnancy and contraception

    • The female member ages 14 through 44 is not pregnant and is using contraception.
    • The member has an intrauterine device or implant.
    • The member has a history of hysterectomy, tubal ligation, or endometrial ablation.
  25. The required pain agreement remains completed.
  26. Concomitant benzodiazepine and opioid use is managed under the care of, or referral to, a mental health provider.

    27. Extended-Use Exception Continuation

    Continuation or repeat use under an extended exception remains subject to the applicable quantity limit and all exception criteria.

    Extended exception continuation

    • Applicable exception

      • The member continues to qualify for the burn or corrosion recovery exception, including the applicable burn-center referral or rural-access circumstance.
      • The member continues to qualify for the sickle cell disorder exception.
      • The member resides in a Medicaid-certified nursing facility.
    • The applicable signed and faxed attestation, supporting documentation, and patient-specific clinical action plan remain current; long-term-care requests also include the pre-admission evaluation form.
    • The member has moderate-to-severe pain that is inadequately responsive or non-responsive to non-opioid analgesic treatment and significantly impairs physical functioning, where required.
    • The prescriber has completed the applicable SBIRT assessment and current controlled-substance database review.
    • The patient is not currently undergoing active treatment for opioid addiction.

    • Pregnancy and contraception

      • The female member ages 14 through 44 is not pregnant and is using contraception.
      • The member has an intrauterine device or implant.
      • The member has a history of hysterectomy, tubal ligation, or endometrial ablation.
    • The required pain agreement remains completed.
    • Concomitant benzodiazepine and opioid use is managed under the care of, or referral to, a mental health provider.
    Opioid agents for extended-use exceptions
    Exception quantityUp to 45 days every 90 days
    Covered exceptionsBurn, corrosion, sickle cell, or Medicaid-certified nursing-facility requests
    Dosage limitNo more than 60 MME per day