CurrentUnitedHealthcarePolicy N/A

Levorphanol step therapy — UnitedHealthcare Pharmacy Clinical Pharmacy Programs

Defines step therapy requirements for coverage of levorphanol under UnitedHealthcare Pharmacy Clinical Pharmacy Programs; applies to members whose benefit plans use this program and to providers seeking prior authorization for levorphanol.

Policy Summary

PayerUnitedHealthcare

PolicyLevorphanol step therapy — Pharmacy Clinical Pharmacy Programs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting failure, contraindication, or intolerance to at least three specified step‑1 opioids before requesting coverage of levorphanol.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3required prior step-1 medication failures

12 moauthorization duration

2/1/2025effective date

Jan 2024package insert reference date

Coverage Criteria

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Approval and coverage of levorphanol are subject to state mandates, any applicable federal regulatory requirements, and the member’s specific benefit plan terms; these plan-level limitations may alter whether or how the criteria below are applied. Other UnitedHealthcare policies and utilization management programs may also affect coverage decisions. Additionally, UnitedHealthcare may use automated processes and prior claim/medication history, diagnosis codes (ICD‑10), and claim logic to grant initial approvals or reauthorizations in lieu of the standard criteria when appropriate.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Coverage of levorphanol requires prior authorization. Authorization will be issued for up to 12 months. State mandates, federal regulatory requirements, and the member's benefit plan may affect coverage decisions.

Authorization duration: 12 months
Coverage may be impacted by state/federal mandates and member benefit plan

Step Therapy

Step Therapy Requirement

Step therapy requirement — Approval is contingent on documentation of failure, contraindication, or intolerance to at least three specified step‑1 opioids prior to initiating levorphanol.

Required trial of at least THREE of the following step‑1 opioids: hydromorphone (Dilaudid), oxycodone (Roxicodone), morphine immediate‑release, oxymorphone (Opana)
Failure, contraindication, or intolerance must be documented

Denial Risk

Documentation and Denial Risk

Step therapy failure / documentation requirement — If the provider does not document history of failure, contraindication, or intolerance to at least three of the specified step‑1 opioids, coverage may be denied. Acceptable sources of documentation include prior claims/medication history, diagnosis codes (ICD‑10), claim logic, supply limits, and medical records/notes. Automated approval or reauthorization may be granted based on available claims and medication history where applicable.

Denial risk if documentation of trials with ≥3 step‑1 opioids is not provided
Acceptable documentation: previous claims/medication history, ICD‑10 diagnosis codes, claim logic, supply limits, medical notes
Automated approval/reapproval processes may be used depending on program rules

Initial Therapy

Initial coverage

Initial coverage criteria

Initial coverage: Documented failure, contraindication, or intolerance to at least three listed step-1 opioids (hydromorphone; oxycodone; morphine immediate-release; oxymorphone).>=3 agents failed

Meets step therapy requirement for levorphanol

Reauthorization and Continuation

Reauthorization

Reauthorization rules

Reauthorization: Authorization will be issued for 12 months; reauthorization may be granted based on previous claim/medication history, diagnosis codes, and/or claim logic subject to supply limits and medical necessity.12 months

Automated approval processes may be used; state mandates and member-specific benefit plan coverage may affect reauthorization.

Step	Required trial	Coverage
Step 1	Trial of at least three step‑one opioids: hydromorphone; oxycodone; morphine immediate‑release; oxymorphone (documented failure, contraindication, or intolerance to at least THREE).	Coverage allowed with documentation meeting the step‑therapy requirement (prior authorization required). Authorization issued for 12 months upon approval.

Definitions

Step therapy — definitions and related terms

DefinitionStep therapy: a utilization management program requiring trials of lower-step (step‑1) medications before coverage of higher-step medication (levorphanol) is provided.

Step therapy requirementA trial of at least three step‑one medications is required before coverage of levorphanol is approved.

Failure criteriaDocumentation of failure, contraindication, or intolerance to at least three specified step‑1 opioids is required to meet the step therapy requirement.

Prior authorization durationApprovals for levorphanol are issued for 12 months upon meeting step therapy and authorization requirements.

PurposeEncourages use of lower-cost alternatives within the opioid class prior to covering higher-line agents like levorphanol.

Background

Levorphanol is an opioid analgesic indicated for management of pain severe enough to require an opioid when alternative treatments are inadequate. UnitedHealthcare places levorphanol within a step‑therapy framework intended to encourage trials of lower‑step, commonly used opioids before authorizing higher‑line agents such as levorphanol.