CurrentUnitedHealthcarePolicy N/A

Md Opioid Products Prior Authorization Request Form

A UnitedHealthcare prior authorization request form and checklist used in Maryland for opioid medications, documenting member/provider info, clinical justification, prior medication trials, and attestations required to approve new or continuing opioid therapy including special pathways for cancer/sickle cell/hospice, neuropathic pain, postoperative use, quantity-limit and >90 MME considerations, and naloxone guidance.

Policy Summary

PayerUnitedHealthcare

PolicyMd Opioid Products Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the entire Maryland prior authorization form and fax to 866-940-7328, include Section D when indicated, and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted.

Multiple conditional pathwaysCovered Indications

Covered w/o PANaloxone Coverage

24 hoursAllow time for review

Coverage Summary

This UnitedHealthcare Maryland prior authorization form covers requests for opioid medications for both new and continuation of therapy. Approval pathways depend on completed attestations and screening (including prescriber attestation, substance use screening, PDMP review via CRISP, and urine drug screening), the clinical context (e.g., cancer, sickle cell, hospice, post-surgery, neuropathic vs non‑neuropathic pain), documented prior medication trials when required, and demonstration of treatment goals or rationale for ongoing therapy. Specific routes include streamlined continuation when the member is established on the requested medication for cancer/sickle cell/hospice pain (document start date), standard outpatient or inpatient discharge attestations, and special rules for long‑acting opioids, tramadol dosing, and dose/quantity checks including the cumulative dose threshold (90 MME per day).

Medical Necessity Criteria (Attestations, Initial & Continuation)

Non-Preferred Medication Exception

If request is for a non-preferred medication:

ALL of the following

Patient has had failure, contraindication, or intolerance to a trial of at least three preferred short-acting opioids.

Specific Agent Failures (History of failure/intolerance)

Documented failure, contraindication or intolerance to any of the following must be indicated and Section D completed if applicable:

ANY of the following

Fentanyl transdermal (12, 25, 50, 75, and 100 mcg)
Hydrocodone extended-release capsules (generic Zohydro ER)
Morphine sulfate-controlled release tablets (generic MS Contin)
Oxymorphone ER non-crush resistant (generic)

Tramadol Specifics

Tramadol prior authorization considerations:

ALL of the following

Document whether patient has history of failure, contraindication or intolerance to trial of tramadol immediate release (IR); complete Section D if yes.
For requests for Tramadol 100 mg tablets: Provide rationale for need to use 100 mg tablet instead of two 50 mg tablets.
100 mg justification

Cancer / Sickle Cell / Hospice Related Pain

Special rules for these populations:

ALL of the following

If treating cancer-related, sickle cell, or hospice pain and patient is established on the requested medication and it is not a new regimen for that indication, document start date.

Non-Cancer / Non-Sickle Cell / Non-Hospice Pain - Long-acting Opioids

Requirements prior to starting long-acting opioids:

ALL of the following

Patient failed an adequate (minimum of 2 week) trial of a short-acting opioid within the last 30 days.minimum of 2 weeks within last 30 days
Complete Section D when applicable

Neuropathic Pain Requests

For neuropathic pain (e.g., neuralgias, neuropathies, fibromyalgia):

ALL of the following

If neuropathic pain request
- Patient exhibited inadequate response to 8 weeks of gabapentin titrated to a therapeutic dose8 weeks titrated to therapeutic dose
  Check box if gabapentin contraindicated.
- Patient exhibited inadequate response to at least 6 weeks of a tricyclic antidepressant titrated to maximum tolerated doseat least 6 weeks
  Check box if tricyclic antidepressant contraindicated.

Quantity Limit & >90 MME Cumulative Threshold

Dose and quantity limit checks:

ALL of the following

Can the requested dose be achieved by moving to a higher strength of the product? If yes, list reasoning for not switching.
Is the requested dose within FDA maximum dose per day where an FDA maximum exists? (See table on page below).
FDA max table
Has the patient tried and failed non-opioid pain medications? If yes, complete Section D.
Have opioid medication doses of less than 90 MME been tried and did not adequately control pain? If yes, complete Section D.trial of doses < 90 MME attempted and inadequate

New to Therapy for Short Acting Opiates Only

For patients new to short-acting opioid therapy:

ANY of the following

Traumatic injury
Post-surgical procedures, excluding dental procedures
Prescriber attests that the patient has received an opioid within the past 60 days

ALL of the following

If requested for traumatic injury or post-surgical procedure, prescriber attests that based on injury/surgery the member requires greater than a 7-day supply for patients 20 years and older or greater than a 3-day supply for patients under age 20 to adequately control pain.> 7-day supply (age >=20); > 3-day supply (age <20)

Continuation of Therapy

Criteria for continuing opioid therapy:

ALL of the following

Patient has demonstrated meaningful improvement in pain and function when assessed against treatment goals. Document improvement in function or pain score.
If treatment goals not met, rationale has been identified for not tapering and discontinuing opioids; document rationale.

Provider Actions & Requirements

Prior Authorization

Submit completed PA form and documentation

Complete entire Pennsylvania Maryland prior authorization form (all pages) and fax to 866-940-7328; allow at least 24 hours for review; include Section D prior medication trials when indicated.

Fax: 866-940-7328
Allow at least 24 hours for review

Documentation Required

Attestations and clinical documentation required

Prescriber must attest to PDMP review (CRISP), screenings for substance use, naloxone offered/provided, patient-prescriber agreement for outpatients, prior trial failures, and pain/treatment goals; Section D must document prior medications, strengths, dates, and reasons for discontinuation when required.

Review PDMP (CRISP) before prescribing
Perform urine drug screening (random UDS) as part of ongoing therapy
Offer/provide naloxone to patient/patient's household
Maintain Patient‑Prescriber Pain Management/Opioid Treatment Agreement for outpatients
Complete Section D with prior medications, strengths, dates, and reasons for discontinuation

Documentation Required

Cancer/sickle cell/hospice continuity documentation

If established on requested medication for cancer-related, sickle cell, or hospice-related pain and it is not a new regimen, list the medication start date to support continuation.

Documentation Required

Tramadol 100 mg justification

Provide rationale for use of 100 mg tramadol tablet instead of two 50 mg tramadol tablets when requesting the 100 mg tablet; document prior trial of tramadol IR in Section D if applicable.

Billing Rule

Naloxone coverage

Opioid overdose reversal medications are a covered benefit without prior authorization; CDC guidelines recommend offering naloxone to patients at increased risk of overdose per CDC criteria.

Covered without prior authorization

Denial Risk

Incomplete form may delay/deny request

Failure to complete all pages, required attestations, or Section D when indicated may delay the decision or result in denial.

Missing pages of the form
Missing required attestations (e.g., PDMP, UDS, naloxone, treatment goals)
Omitted Section D documenting prior medication trials when indicated

Background

The Maryland prior authorization form is used to gather the member and prescriber information, the clinical indication and diagnosis (including an ICD‑10 code), medication details, and prior medication trials (Section D) necessary to review opioid medication requests. The form must be completed in full and faxed for review; allow at least 24 hours for a decision.

The form enforces safety practices by requiring attestations that the prescriber reviewed the state Prescription Drug Monitoring Program (PDMP/CRISP), screened the patient for substance use/opioid dependence, arranged urine drug screening when indicated, offered or provided naloxone, and discussed opioid risks/benefits with the patient/household. It also documents prior treatment failures, contraindications or intolerances (with Section D detailing trials, strengths, dates, and reasons for discontinuation) and treatment goals to support approval or continuation of therapy.

PDMP (CRISP): Prescription Drug Monitoring Program used in Maryland (CRISP) to review controlled substance prescriptions — prescribers must attest they reviewed CRISP before prescribing opioids for outpatient and inpatient discharge requests.

MME: Morphine milligram equivalents; threshold referred to is 90 MME cumulative per day — the form requires consideration of whether opioid doses <90 MME were tried and documents quantity limit and dose checks (including FDA maximum dose per day where applicable).

Revision History

policy_summaryLatest

Prior authorization form requires completion of entire form and faxing for review (allow at least 24 hours); documents member/provider info, diagnosis (ICD-10), prior medication trials (Section D), and attestations to support opioid initiation or continuation.

safety_requirementsLatest

Prescriber must attest to PDMP (CRISP) review, screening for substance abuse/opioid dependence, provision/offering of naloxone, and patient-prescriber agreement and random urine drug screens for outpatients; inpatient discharge attestations require PDMP review and naloxone provision/offering.

treatment_requirementsLatest

For long-acting opioids, patient must have moderate to severe pain expected to persist (chronic) and failed an adequate minimum 2-week trial of a short-acting opioid within the last 30 days; continuation requires documented meaningful improvement in pain and function or documented rationale for not tapering if goals not met.

non_preferred_exceptionLatest

For non-preferred medications, prescriber must document failure/contraindication/intolerance to at least three preferred short-acting opioids and complete Section D with prior medication details.

neuropathic_pain_rulesLatest

For neuropathic pain, unless contraindicated, document inadequate response to 8 weeks of gabapentin titrated to therapeutic dose or at least 6 weeks of a tricyclic antidepressant titrated to maximum tolerated dose.

tramadol_specificsLatest

For tramadol, document prior IR tramadol failure if applicable; requests for 100 mg tablets require rationale for using 100 mg instead of two 50 mg tablets.

dose_and_quantity_checksLatest

Form requires checking if requested dose can be achieved by higher strength, if dose is within FDA maximum where applicable, whether non-opioid therapies and trials below 90 MME were tried and failed; >90 MME considerations documented.

post_surgical_supply_limitLatest

For traumatic injury or post-surgical short-acting opioid requests, prescriber must attest if member requires >7-day supply (age ≥20) or >3-day supply (age <20) based on surgery/injury.

special_populationsLatest

If treating cancer-related, sickle cell, or hospice pain and patient is established on requested medication (not a new regimen), prescriber should list start date to support continuation.

OpenPayer

Md Opioid Products Prior Authorization Request Form

Coverage Summary

Medical Necessity Criteria (Attestations, Initial & Continuation)

Coding

Provider Actions & Requirements

Background

Revision History