CurrentUnitedHealthcarePolicy N/A

Opioid-related Pharmacy Point-of-Sale and Utilization Management Criteria

Defines UnitedHealthcare Community Plan pharmacy point-of-sale and utilization management programs addressing opioid prescribing, co-prescribing risks, dosage limits, prior authorization, and retrospective review affecting prescribers, pharmacists, and members in the plan.

Policy Summary

PayerUnitedHealthcare

PolicyOpioid-related Pharmacy Point-of-Sale and Utilization Management Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization to exceed the 90 MME/day cumulative opioid limit or for concurrent long-acting opioid therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MMEpoint-of-sale cumulative opioid dose limit

3- or 7-daySAO supply limit

4 g/dayacetaminophen max/day

24/7member support

Coverage Criteria

Point-of-sale coverage and limits

Policy Summary

PayerUnitedHealthcare

PolicyOpioid-related Pharmacy Point-of-Sale and Utilization Management Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization to exceed the 90 MME/day cumulative opioid limit or for concurrent long-acting opioid therapy.

SourceLink

On This Page

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POS dose and supply limits: Cumulative opioid dosing at point-of-sale must be <= 90 MME per day; combination opioid products containing acetaminophen must not result in total acetaminophen > 4 grams per day; short-acting opioid (SAO) fills limited to either a 3-day supply per fill (with up to 2 fills in a rolling 30 days) or a 7-day supply per fill (with up to 2 fills in a rolling 30 days) when an 'acute pain exception' is written on the prescription.<= 90 MME/day; <= 4 g APAP/day; 3- or 7-day SAO limits

Exceeding these limits prevents processing at point-of-sale or requires prior authorization.

High-risk concurrent therapy alerts: Point-of-sale and cDUR alerts identify concurrent use of opioids with benzodiazepines, antipsychotics, sedative-hypnotics, skeletal muscle relaxants, medication-assisted treatment (MAT) drugs, prenatal medications, overlapping LAOs or SAOs, and other high-risk combinations; pharmacist or prescriber must address these alerts per workflow.N/A

Enhanced alerts (e.g., for >50 MME) may recommend offering an opioid antagonist; some enhanced alerts do not require entry of NCPDP codes by pharmacist.

Prior authorization-covered conditions

Prior authorization required in the following scenarios:

PA for doses above MME threshold: Prior authorization is required for opioid doses above the preset cumulative 90 MME per day threshold.>90 MME/day

Claims above the threshold are prevented from processing at point-of-sale until PA is obtained.

PA for multiple LAOs: Prior authorization is required for concurrent use of multiple long-acting opioids (duplicate LAO therapy).N/A

LAO PA requires documentation of appropriate use criteria for non-cancer pain and step therapy evidence; intensive reauthorization review criteria apply.

PA for transmucosal fentanyl: Transmucosal fentanyl products require prior authorization documenting that the pain is due to cancer and that the patient is already receiving opioids.N/A

Non-cancer use is not authorized under this PA criterion.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required to exceed the cumulative 90 MME per day limit, for concurrent use of multiple long-acting opioids (LAOs), and in other specified scenarios described below.

Point-of-sale dosage limit: cumulative opioid doses up to 90 MME per day are permitted; claims that would exceed this threshold are prevented from processing at point-of-sale and require prior authorization.
Prior authorization required for concurrent use of multiple LAOs; concurrent (duplicate) long-acting opioid therapy will be denied without an approved prior authorization.
Prior authorization is required to exceed SAO duration/quantity limits (e.g., 3-day supply per fill with 2 fills in 30 days, or 7-day supply per fill with 2 fills in 30 days with an acute pain exception) and to exceed the <90 MME per day dose limit.

Step Therapy

LAO Step Therapy

LAO prior authorization requires step therapy and adherence to preferred product sequencing and condition-specific alternatives.

Step through short-acting opioids (SAO) for non-cancer pain before approval of long-acting opioids.
Step through preferred long-acting opioids when applicable.
For non-cancer neuropathic pain, applicants may be required to step through neuropathic pain alternatives prior to LAO approval.

Documentation Required

PA Documentation Requirements

Prior authorization for LAOs must include documentation that supports appropriate use and the required step-therapy pathway.

Documentation of diagnosis and indication (e.g., non-cancer chronic pain) and supporting clinical rationale.
Evidence of trial and failure or intolerance of required short-acting opioids for non-cancer pain, and evidence of trials of preferred LAOs when required.
If relevant, documentation that neuropathic pain alternatives were tried when LAO is requested for neuropathic pain.
For transmucosal fentanyl products, documentation must show pain due to cancer and that the patient is already receiving opioid therapy.
For reauthorization requests, provide documentation meeting intensive reauthorization review criteria as specified by the plan.

Denial Risk

MME Threshold Denial Risk

Claims that would result in cumulative opioid doses above the preset 90 MME per day threshold will be prevented from processing at point-of-sale and require prior authorization to be filled.

When prevented at point-of-sale, prescribers or pharmacies must complete the prior authorization process for doses above 90 MME/day.
Failure to obtain approval will result in claim denial or prevention at POS.

Denial Risk

LAO Duplicate Therapy Denial Risk

Concurrent use of multiple long-acting opioids triggers prior authorization and may be denied without approval.

Concurrent LAO prescriptions will be reviewed and require justification; absence of approved PA may result in denial.
Prior authorization for duplicate LAO therapy must demonstrate clinical necessity and adherence to step therapy and documentation requirements.

Background

UnitedHealthcare Community Plan programs implement CDC-aligned opioid prescribing measures to promote appropriate opioid use, reduce risk of misuse, and identify members and prescribers who may be at risk. These measures include a point-of-sale cumulative opioid dosing limit of 90 MME per day, duplicate-therapy controls that require prior authorization for concurrent long-acting opioids, short-acting opioid fill-duration limits (a 3-day supply per fill with up to 2 fills in a rolling 30 days or a 7-day supply per fill with up to 2 fills in a rolling 30 days when an 'acute pain exception' is written), and retrospective review to identify outlier prescribing and potentially dangerous combinations. Prior authorization is required when claims exceed the preset thresholds or when intensified review is indicated (for example, multiple long-acting opioids or transmucosal fentanyl without required cancer-related documentation).

Definitions

MME (Morphine Milligram Equivalent)

DefinitionMorphine Milligram Equivalent (MME) — used as the cumulative opioid dosage threshold at point-of-sale.

Preset thresholdPoint-of-sale cumulative limit set at 90 MME per day; claims above this threshold are prevented from processing and require prior authorization.

cDUR and rDUR

cDUR (Concurrent DUR)Screens prescriptions at point-of-sale using claims processing edits and messaging; pharmacists must address alerts at point-of-sale.

rDUR (Retrospective DUR)Analyzes claims daily and sends communications to prescribers; identifies patterns such as overlapping opioids and high daily doses.

Initial Therapy Criteria

Buprenorphine MAT initiation

Buprenorphine induction for medication-assisted treatment (MAT):

Buprenorphine initial supply: Prescribers may prescribe a 7-day supply of buprenorphine for initiation of medication-assisted treatment (MAT) when starting members.7-day supply

Supports induction without requiring longer-term prior authorization at initiation.

Step Therapy

Step	Requirement	Notes / Documentation
1	Step through short-acting opioids (SAO)	Required for non-cancer pain prior to approval of long-acting opioids (LAO)
2	Step through preferred long-acting opioids (preferred LAOs)	Provider must document trial/failure or contraindication to preferred LAOs
3	For non-cancer neuropathic pain: step through neuropathic pain alternatives if appropriate	Documentation of trial or contraindication to neuropathic alternatives may be required
4	Concurrent use of multiple LAOs	Prior authorization required; concurrent LAOs may be denied without approval
5	Requests that result in cumulative opioid doses > 90 MME/day	Claims prevented at point-of-sale until prior authorization is obtained

Quantity Limits

Short-acting opioid (SAO) quantity limits

Standard SAO supply limit3-day supply per fill with up to 2 fills in a rolling 30-day period

Acute pain exception7-day supply per fill with up to 2 fills in a rolling 30-day period when 'acute pain exception' is written on the prescription

PA for exceeding quantitiesPrior authorization is required to exceed these SAO duration/quantity limits.

Acetaminophen in combination opioids

Acetaminophen component limitWhen present in combination opioids, acetaminophen is limited to <= 4 grams per day

POS enforcementHigh-dose acetaminophen is prevented by cDUR point-of-sale edits to avoid >4 g/day exposures

OpenPayer

Opioid-related Pharmacy Point-of-Sale and Utilization Management Criteria

Coverage Criteria

Coding and Limits

Provider Actions and Requirements

Background

Definitions

Initial Therapy Criteria

Step Therapy

Quantity Limits

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