CurrentUnitedHealthcarePolicy N/A

Opioid utilization management and cDUR program - Pharmacy

Defines UnitedHealthcare Community Plan's concurrent and retrospective drug utilization review (cDUR/rDUR) and utilization management controls for opioid prescribing and dispensing for plan members, including point-of-sale edits, prior authorization requirements, and pharmacy lock-in criteria.

Policy Summary

PayerUnitedHealthcare

PolicyOpioid utilization management and cDUR program - Pharmacy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization before dispensing long-acting opioids to opioid‑naïve members or when cumulative opioid doses will exceed preset point-of-sale limits (e.g., >90 MME).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 MMEpoint-of-sale cumulative opioid dose limit

7 daysopioid‑naïve definition

10-dayopioid‑naïve max supply

120 mLcough/cold product limits

36/60 mopossible lock-in duration

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Coverage Criteria and Utilization Controls

Point-of-sale and cDUR criteria

Covered when prescribing and dispensing meet point-of-sale and prior authorization requirements and do not violate program limits.

Point-of-sale checks: Claims are screened at point-of-service for drug-drug interactions (e.g., opioids with antipsychotics, benzodiazepines, MAT, sedative hypnotics, muscle relaxants), duplicate therapy (multiple short-acting or long-acting opioids), high-dose acetaminophen in combination products, and cumulative MME limits.see thresholds

Some interactions generate alerts only; concurrent opioids and benzodiazepines require prior authorization.

Opioid‑naïve therapy controls

Requirements specific to opioid‑naïve members and long-acting opioids.

Opioid‑naïve limits: For members with less than or equal to 7 days of opioid use in the prior 60 days, point-of-sale limits a current fill to a maximum 10-day supply and <= 90 MME per day.<=7 days in prior 60 days; max 10-day supply; <=90 MME/day

Prior authorization is required to fill long-acting opioids or to exceed these quantity or MME limits.

Transmucosal fentanyl

Transmucosal fentanyl prior authorization requirements.

Transmucosal fentanyl: Prior authorization requires documentation that the pain is due to cancer and that the patient is already receiving opioid therapy.cancer-related pain; current opioid therapy

Applies to transmucosal fentanyl products.

Cough/cold opioid product limits

Quantity limits and age-based prior authorization for pediatric members.

Cough/cold opioid products: Limits quantities per fill to 120 mL (units) and a 30-day maximum of 360 mL (units); prior authorization is required for members under age 18.120 mL per fill; 360 mL per 30 days

Pediatric prior authorization required.

Retrospective review and abuse identification

rDUR and abuse-detection workflows.

Retrospective DUR and abuse detection: rDUR analyzes claims daily to identify members with multiple opioid prescriptions from multiple prescribers and/or pharmacies, chronic early refill attempts, overlapping short-acting or long-acting therapies, high daily MME, opioid overdose diagnoses followed by opioid fills, and overlapping therapies with MAT, benzodiazepines, antipsychotics, muscle relaxants, or opioid potentiators; patient-specific fill histories for the prior 4 months are sent to prescribers.4 months history

May trigger outreach, prescriber communication, or referral to pharmacy lock-in program; also identifies outlier prescribers.

Preferred naloxone products are excluded from prior authorization requirements. Examples include generic naloxone injection and Narcan® Nasal Spray; these preferred formulations may be dispensed at point-of-sale without obtaining prior authorization.

Dose, Supply and Quantity Limits (Coding Summary)

inv-07: Cumulative opioid dose limit — 90 MME

Cumulative opioid dose limit90 MME (point-of-sale cumulative limit)

Processing behaviorClaims that would cause cumulative opioid doses to exceed 90 MME are prevented from processing unless prior authorization is obtained

Prior authorization triggerPrior authorization required for doses above the 90 MME preset threshold

inv-08: Opioid‑naïve supply limit — <= 7 days in last 60 days; max 10-day supply and <= 90 MME/day

Opioid‑naïve definition for supply limitsMember with ≤7 days of opioid supply in the prior 60 days qualifies as opioid‑naïve

Point-of-sale quantity limit for opioid‑naïve membersMaximum 10-day supply per fill

Provider Requirements, Prior Authorization, and Claims Handling

Prior Authorization

Prior Authorization Required for Concurrent Opioid + Benzodiazepine Prescribing

Concurrent prescribing of opioids and benzodiazepines requires prior authorization. At point-of-sale, claims that indicate concurrent use of opioids and benzodiazepines will trigger a prior authorization requirement rather than a pharmacist NCPDP override; prescribers and dispensing pharmacies must obtain authorization before the claim will process.

Applies to overlapping opioid + benzodiazepine fills
Point-of-sale alert will require prior authorization to process claim

Prior Authorization

Prior Authorization for Long‑Acting Opioids and Exceeding Point‑of‑Sale Limits

Prior authorization is required to fill long-acting opioids (LAOs) for opioid‑naïve members (defined as ≤7 days opioid supply in the prior 60 days) and to exceed point-of-sale quantity and MME limits for new-to-therapy short-acting opioids. For opioid‑naïve members the edit includes a maximum 10‑day supply and ≤90 MME per day; dispensing LAOs or exceeding these quantities requires an approved prior authorization.

Opioid‑naïve = ≤7 days opioid supply in last 60 days

Initial Therapy Controls for New Opioid Starts

Initial therapy controls

Controls applied when initiating opioid therapy for opioid‑naïve members.

Initial opioid therapy limits: Point-of-sale limit for opioid‑naïve members: qualifying as opioid‑naïve requires <=7 days opioid supply in the prior 60 days; the current fill is limited to a maximum 10-day supply and <=90 MME per day.

Prior authorization is required to initiate long-acting opioids (LAOs) in opioid‑naïve patients or to exceed these supply or MME limits.

Step Therapy Requirements

Step	Requirement	Coverage
1	Prior authorization is required before dispensing long-acting opioids to opioid‑naïve members (opioid‑naïve defined as ≤7 days opioid use in the prior 60 days).	Prior authorization required

Quantity Limits and Special Product Rules

inv-21: Cough/cold products containing opioid components — 120 mL per fill; 360 mL per 30 days

Per-fill limit (cough/cold with opioid)120 mL (units) per fill

30-day maximum360 mL (units) per 30 days

Pediatric requirementPrior authorization required for members under 18

Designated Dispensing and Lock-in Program

Billing Rule

Pharmacy lock-in: single designated pharmacy required

When a member is enrolled in the pharmacy lock-in program they are required to use a single designated pharmacy for opioid dispensing.

Lock-in setting: pharmacy; member must fill opioids at the designated single pharmacy while enrolled in the program.

Key Definitions Used in This Policy

inv-17: Opioid‑naïve definition — member with <= 7 days of opioid supply in the prior 60 days

Opioid‑naïve definition (supply-based)Member with ≤7 days of opioid supply in the prior 60 days is considered opioid‑naïve

Use in point-of-sale editsThis definition triggers initial therapy controls limiting supply and MME for new-to-therapy fills

Implication for LAOOpioid‑naïve members require prior authorization to fill long‑acting opioids

inv-18: MME definition — morphine milligram equivalent used as cumulative daily opioid dosage metric; program enforces a 90 MME point-of-sale cumulative limit

DefinitionMorphine milligram equivalent (MME) used as the cumulative daily opioid dosage metric

Program enforcementProgram enforces a 90 MME point-of-sale cumulative limit across opioid products

Background and Rationale

UnitedHealthcare’s opioid utilization management program aligns with CDC opioid-prescribing guidance to reduce misuse and harm from both short-acting and long-acting opioids. The program applies point-of-sale screening and retrospective review to identify high-risk patterns such as overlapping opioid therapies, high cumulative daily dose (enforced at 90 MME), multiple prescribers or pharmacies, early refill attempts, and combinations with central nervous system depressants; these controls are intended to promote safer prescribing and support outreach and care management interventions.

Policy Summary

PayerUnitedHealthcare

PolicyOpioid utilization management and cDUR program - Pharmacy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization before dispensing long-acting opioids to opioid‑naïve members or when cumulative opioid doses will exceed preset point-of-sale limits (e.g., >90 MME).

SourceLink

On This Page

MME/day limit for opioid‑naïve fills≤90 MME per day

Prior authorization requirementPrior authorization required to fill long‑acting opioids or to exceed the 10‑day/90 MME limits

inv-09: Cough/cold opioid product limits — 120 mL per fill; 360 mL per 30 days

Per-fill limit120 mL (units) per fill

30-day maximum360 mL (units) per 30 days

Pediatric prior authorizationPrior authorization required for members under age 18

inv-10: Refill-too-soon threshold — 90% threshold for opioids and other Schedule CII-V controlled substances

Refill-too-soon threshold90% threshold for opioids and other Schedule CII-V controlled substances

ScopeApplies to opioids and other Schedule CII-V controlled substances at point-of-sale refill checks

Program purposeAims to reduce early refill attempts and misuse through stricter refill timing enforcement

Maximum for opioid‑naïve new-to-therapy SAO: 10‑day supply and ≤90 MME/day

Prior authorization required to fill LAOs for opioid‑naïve members

Prior authorization required to exceed point-of-sale quantity/MME limits

Denial Risk

Claims Prevention for Exceeding 90 MME Cumulative Limit

Claims that would cause cumulative opioid doses to exceed the 90 MME point-of-sale limit will be prevented from processing unless prior authorization is obtained. Pharmacists and prescribers should initiate the prior authorization process when a member’s cumulative MME would surpass the preset threshold to avoid claim denials at the point-of-sale.

Cumulative limit: 90 MME at point-of-sale
Processing prevented when cumulative opioid doses exceed limit without PA
Prior authorization required for doses above the preset threshold

Documentation Required

Prior Authorization Forms and Documentation Resources

Forms and documentation requirements for pharmacy prior authorizations are available on the payer’s Pharmacy Resources and Physician Administered Drugs page. Clinicians should use the specified prior authorization forms and include requested clinical documentation (for example, history of opioid use, indication such as cancer-related pain for certain agents, and justification for concurrent therapy) to support approvals.

Access Pharmacy prior authorization forms and instructions on the Pharmacy Resources and Physician Administered Drugs page
Include clinical documentation per form instructions (e.g., pain diagnosis, prior opioid exposure, rationale for concurrent therapies)
Transmucosal fentanyl PAs require documentation of cancer-related pain and existing opioid therapy where applicable

Note

Concurrent Prescribing Alerts for Other High‑Risk Combinations

Concurrent-prescribing alerts also exist for other high-risk combinations (e.g., opioids with antipsychotics, sedative-hypnotics, skeletal muscle relaxants, and medications used in medication‑assisted treatment). Some of these interactions generate enhanced point-of-sale alerts that recommend pharmacist intervention or outreach; however, only specific combinations (notably opioid + benzodiazepine) require prior authorization.

Point-of-sale alerts for opioids + antipsychotics, sedative-hypnotics, muscle relaxants, and MAT drugs
Enhanced alerts may recommend offering naloxone for doses >50 MME
Only certain overlaps (opioid + benzodiazepine) trigger PA requirement

Authorization consequencePrior authorization is required for doses above the 90 MME threshold