CurrentUnitedHealthcarePolicy N/A

Opioid Analgesic Prior Authorization for Chronic Pain

Form and criteria governing prior authorization requests for long-acting opioid analgesics for chronic non-malignant pain and related prescribing documentation; affects prescribing providers and pharmacy PA reviewers for UnitedHealthcare beneficiaries in North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicyOpioid Analgesic Prior Authorization for Chronic Pain

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionInclude completed beneficiary and prescriber information, drug details, clinical justification, prior therapy documentation, PDMP check, and prescriber signature when submitting a prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90morphine-equivalent threshold (mg)

>=4 wksminimum chronic pain duration

2preferred product trials required

NCstate PDMP

Coverage and Authorization Criteria

Authorization Criteria

Covered when ALL of the following are met:

Patient eligibility: Patient does not have malignant cancer or pain due to neoplasm (if yes, patient is exempt from authorization)

Malignant cancer patients are exempt

Chronic pain duration: Beneficiary has chronic pain syndrome of at least four (4) weeks duration>= 4 weeks

Dosing and justification: Requested total daily opioid dose in combination with other opioids is <= 90 mg morphine-equivalent OR if > 90 mg, provider supplies diagnosis/reason and duration for exceeding the limit<= 90 mg or documented justification

Policy Summary

PayerUnitedHealthcare

PolicyOpioid Analgesic Prior Authorization for Chronic Pain

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

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Prior Authorization Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-exempt long-acting opioid requests. Include the drug name, strength, quantity per 30 days, and requested length of therapy on the PA request. Provide clinical justification that supports medical necessity and adherence to prescribing guidelines.

Drug name, strength, quantity per 30 days, and length of therapy (select: up to 30, 60, 90, 120, 180, 365, Other)
Clinical justification and treatment plan (evaluation, informed consent, periodic review)
Prescriber NPI and contact phone number
Beneficiary full name, date of birth, and member ID

Documentation Required

Documentation for Doses Exceeding 90 mg MED/day

Requests that exceed 90 mg morphine equivalent dose (MED) per day require explicit documentation. The request must state the beneficiary's diagnosis, the specific clinical rationale for exceeding the 90 mg MED/day limit, and the duration (days supply) the higher dose is anticipated. If documentation is insufficient, the request may be denied or returned for clarification.

Document beneficiary diagnosis and reason for exceeding 90 mg MED/day
Specify number of days supply the beneficiary will exceed the 90 mg MED/day threshold
Include supporting clinical notes and any specialist consultation if applicable

Documentation Required

Required Submission Fields

Complete fields for beneficiary and prescriber, drug details, and the clinical questionnaire. Missing or incomplete fields may delay processing.

Beneficiary: last name, first name, beneficiary ID #, date of birth, gender
Prescriber: prescribing provider NPI #, requester contact name and phone number, prescriber signature and date (signature mandatory)
Drug: drug name, strength, quantity per 30 days, length of therapy (select appropriate days)
Clinical: diagnosis (including whether malignant cancer or neoplasm-related pain), chronic pain duration (≥4 weeks), whether this is initial authorization, whether a short-acting opioid was tried in past 45 days (if initial), adherence to treatment guidelines (evaluation, treatment plan/contract, informed consent, periodic review), PDMP check confirmation, review of CDC opioid prescribing guideline

Step Therapy

Preferred Product Trial Requirement

Step-therapy requirement: prior trial of two preferred long-acting opioids is required unless contraindicated. Provide documentation of trials or a documented contraindication/allergy to preferred products.

Confirm documented history within the past year of trials of two preferred long-acting opioid analgesics at an equivalent dose to the requested non-preferred product OR
Document contraindication or allergy to ingredients in preferred products (list agents and nature of contraindication)
If no documented trials or contraindication, the request is subject to step-therapy denial or will be returned for additional information

Step Therapy and Trial Requirements

2 preferred long-acting opioid trials or documented contraindication

For requests for a non-preferred long-acting opioid:

ONE of: Documented history within the past year of two preferred long-acting opioid analgesics at a dose equal to or equivalent to the non-preferred product being prescribed2 preferred trials in past year

List agents and dates on the form

ONE of: Documented contraindication or allergy to ingredients in the preferred product

Provider must list contraindication/allergy on the form

Short-acting opioid trial or explanation

Initial authorization requests:

Initial short-acting opioid trial requirement: Beneficiary has tried a short-acting opioid analgesic in the past 45 days45 days

Captured by question 4a on the form

If no short-acting trial: Provider documents an explanation for why a short-acting opioid was not tried

Captured by question 4b on the form

Definitions and Thresholds

inv-11: Chronic pain syndrome

DefinitionChronic pain syndrome = pain of at least four (4) weeks duration as queried on the form

Form locationCaptured by question 2 on the Clinical Information section

Relevance to coverageAffirms chronic non-malignant pain duration criterion used for authorization assessment

inv-12: Morphine-equivalent dose threshold

Review thresholdA daily total of 90 mg morphine-equivalent is used as the review threshold

Requirement if exceededResponses >90 mg require documentation of diagnosis/reason and duration (questions 3a and 3b) to justify exceeding the limit

How appliedApplies to requested daily dose combined with other concurrent opioids as asked on the form

Policy Background and Purpose

This authorization form is used to evaluate requests for long-acting opioid analgesics for chronic pain. It distinguishes patients with malignant disease—who are exempt from the authorization requirement—by asking whether the beneficiary has malignant cancer or pain due to neoplasm. The form collects key clinical details used to determine medical necessity, including duration of pain (queries chronic pain of at least four (4) weeks), total daily opioid dose (asks whether the combined daily dose is ≤ 90 mg morphine-equivalent and, if exceeded, requests diagnosis, reason, and duration), whether the request is an initial authorization (and if so, whether a short-acting opioid was tried in the prior 45 days), adherence to opioid management elements (evaluation, treatment plan/contract, informed consent, periodic review), PDMP check, CDC guideline review, and prescriber signature. For non-preferred long-acting opioids, the form requires documentation of trials of two preferred long-acting opioids within the past year or a documented contraindication.

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