CurrentWashington State Health Care AuthorityPolicy 65.10.00.50-3

Methadone

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Washington State Health Care Authority Medicaid fee-for-service coverage and prior authorization requirements for methadone products, including clinical criteria, dose and quantity limits, documentation, billing codes, and approval durations.

Policy Summary

PayerWashington State Health Care Authority

PolicyMethadone

Policy CodePolicy 65.10.00.50-3

Change TypeMaterial policy revision

Effective DateAugust 1, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization for all methadone prescriptions.

SourceLink

POLICY UPDATE CHANGES

Expedited authorization criteria were removed because expedited authorization does not apply to methadone.

Eligibility criteria were expanded to include cancer pain, hospice, palliative care, and end-of-life care.

Initial and reauthorization approval durations were changed to 12 months.

The policy was updated to apply the maximum daily morphine equivalent criteria when methadone doses exceed 20 mg per day or when combined opioid use exceeds 120 MME per day.

RequiredPrior authorization

20 mg/dayMethadone limit

12 monthsInitial approval

12 monthsReauthorization

120 MME/dayMME threshold

2Preferred opioids to try

Coverage Criteria

Initial therapy for chronic pain

For initial prescriptions, coverage may be considered when all of the following are met:

Initial chronic-pain criteria

Diagnosis: Patient has chronic non-cancer pain.
ONE applicable clinical pathway
- Continuation of current therapy: Continuation of current methadone therapy for severe chronic pain.
- Non-cancer pain opioid trials: For non-cancer pain, trial and failure of all generic long-acting opioids within the last 12 months, unless contraindicated or the patient experienced intolerable adverse effects.Within the last 12 months
- Cancer, hospice, palliative, or end-of-life care: For cancer pain, or for patients in hospice, receiving palliative care, or receiving end-of-life care, trial and failure of two preferred long-acting opioids within the last 12 months, unless contraindicated or the patient experienced intolerable adverse effects.Two preferred long-acting opioids within the last 12 months

Dose and MME requirements

The applicable requirement below applies when the prescribed dose exceeds 20 mg per day or methadone is used with another opioid:

Dose and combination-opioid requirements

Dose above 20 mg per day: Provide documentation of clinical benefit at previous doses and a clear clinical rationale that the patient is likely to benefit from further dose increases; the criteria under Policy 65.10.00 for Maximum Daily Morphine Equivalent apply.Greater than 20 mg per day
Use with another opioid: Calculate MME as part of the prior authorization criteria. If the dose exceeds 120 MME per day, the criteria under Policy 65.10.00 for Maximum Daily Morphine Equivalent apply.Greater than 120 MME per day

Continuation therapy

Reauthorization requests may be approved for 12 months when all of the following are met:

Continuation requirements

Patient continues to meet all initial criteria.
Patient demonstrates clinically meaningful improvement in pain and/or function.

Billing and Coding

Methadone HCPCS CodesHCPCS

S0109	Methadone, oral, 5 mg
J1230	Injection, methadone hcl, up to 10 mg

Methadone dose and quantity limit

DrugMethadone

Daily dose and quantity limit20 mg per day

Doses above the limitRequire documentation of clinical benefit at previous doses and a clear clinical rationale for further dose increases

Combined opioid maximum daily MME threshold

Applies whenMethadone is used in combination with any other opioid prescription

Combined opioid thresholdGreater than 120 MME per day

Related criteriaThe maximum daily Morphine Equivalent criteria under Policy 65.10.00 apply

Provider Actions and Documentation

Prior Authorization

Prior Authorization Required

Methadone prescriptions require prior authorization before approval. Expedited authorization codes 85000000540 and 85000000541 do not apply to methadone products.

Step Therapy

Preferred-Drug Requirement

Non-preferred analgesic opioid agonists require applicable preferred-drug trials before authorization.

Document an inadequate response or documented intolerance due to a severe adverse reaction or contraindication to at least two preferred agents.
If only one preferred agent is available in the class, document an inadequate response to that one agent.
New-to-market drugs in the class are non-preferred and subject to these criteria; consult the current Apple Health Preferred Drug List.

Documentation Required

Initial Chronic-Pain Documentation

For an initial prescription for chronic non-cancer pain, submit documentation showing that one applicable pathway is met.

Continuation of current methadone therapy for severe chronic pain; or
For non-cancer pain, trial and failure of all generic long-acting opioids within the previous 12 months, unless contraindicated or associated with intolerable adverse effects; or
For cancer pain, hospice, palliative care, or end-of-life care, trial and failure of two preferred long-acting opioids within the previous 12 months, unless contraindicated or associated with intolerable adverse effects.

Documentation Required

Documentation for Doses Above 20 mg per Day

For doses greater than 20 mg per day, document clinical benefit at previous doses and a clear clinical rationale that the patient is likely to benefit from further dose increases.

The criteria under Policy 65.10.00 for Maximum Daily Morphine Equivalent (MME) apply.
When methadone is used with another opioid prescription, calculate total MME as part of the prior authorization review.
If the dose exceeds 120 MME per day, the Policy 65.10.00 Maximum Daily MME criteria apply.

Documentation Required

Reauthorization Documentation

Reauthorization requests may be approved for 12 months only when the patient continues to meet all initial criteria and demonstrates clinically meaningful improvement.

Document continued satisfaction of the applicable initial clinical criteria.
Document meaningful improvement in pain and/or function.

Denial Risk

Failure to Meet Prior Authorization Criteria

A request may be denied when required prior authorization is missing or when the applicable clinical criteria are not met.

Methadone must be approved through prior authorization or an applicable exception before coverage.
Denial may result when required clinical documentation is absent or when the patient does not meet the applicable initial criteria.

Denial Risk

Insufficient Reauthorization Evidence

Reauthorization is at risk of denial when the record does not establish continued eligibility or meaningful treatment benefit.

Failure to document that all initial criteria continue to be met may result in denial.
Failure to demonstrate clinically meaningful improvement in pain and/or function may result in denial.

Clinical Background

Opioid agonists are reserved for severe pain that cannot be managed with non-pharmacologic therapies or other pharmacologic treatments. Methadone is a long-acting opioid agonist with strong binding affinity to mu-opioid receptors and may be used to provide analgesia or to treat opioid use disorder.

Initial Methadone Therapy

Initial methadone therapy

Initial methadone therapy requires prior authorization and documentation that all of the following are met:

Methadone prescription has prior authorization.
Methadone may be considered medically necessary when approved under the clinical criteria or an applicable exception.
ALL of the following
- ONE applicable pathway
  - Continuation of current methadone therapy for severe chronic pain.
  - For non-cancer pain, trial and failure of all generic long-acting opioids within the last 12 months, unless contraindicated or the patient experienced intolerable adverse effects.Within the last 12 months
  - For cancer pain, or for patients in hospice, receiving palliative care, or receiving end-of-life care, trial and failure of two preferred long-acting opioids within the last 12 months, unless contraindicated or the patient experienced intolerable adverse effects.Two preferred long-acting opioids within the last 12 months

Methadone Reauthorization

Methadone reauthorization

Methadone reauthorization may be approved for 12 months when all of the following are met:

Patient continues to meet all initial criteria.
Patient demonstrates clinically meaningful improvement in pain and/or function.

Preferred Drug Step Therapy

Step	Requirement	Exception
1	For a non-preferred agent in the analgesic opioid agonist class, document an inadequate response or intolerance due to a severe adverse reaction or contraindication to at least two preferred agents.	If only one preferred agent exists in the class, document an inadequate response or intolerance to that one preferred agent.

Methadone Quantity Limit

Methadone quantity limit

DrugMethadone

Quantity limit20 mg

Maximum per day20 mg per day

Policy Summary

PayerWashington State Health Care Authority

PolicyMethadone

Policy CodePolicy 65.10.00.50-3

Change TypeMaterial policy revision

Effective DateAugust 1, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization for all methadone prescriptions.

SourceLink

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Methadone

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Coverage Criteria

Initial therapy for chronic pain

For initial prescriptions, coverage may be considered when all of the following are met:

Initial chronic-pain criteria

Diagnosis: Patient has chronic non-cancer pain.
ONE applicable clinical pathway
- Continuation of current therapy: Continuation of current methadone therapy for severe chronic pain.
- Non-cancer pain opioid trials: For non-cancer pain, trial and failure of all generic long-acting opioids within the last 12 months, unless contraindicated or the patient experienced intolerable adverse effects.Within the last 12 months
- Cancer, hospice, palliative, or end-of-life care: For cancer pain, or for patients in hospice, receiving palliative care, or receiving end-of-life care, trial and failure of two preferred long-acting opioids within the last 12 months, unless contraindicated or the patient experienced intolerable adverse effects.Two preferred long-acting opioids within the last 12 months

Dose and MME requirements

The applicable requirement below applies when the prescribed dose exceeds 20 mg per day or methadone is used with another opioid:

Dose and combination-opioid requirements

Dose above 20 mg per day: Provide documentation of clinical benefit at previous doses and a clear clinical rationale that the patient is likely to benefit from further dose increases; the criteria under Policy 65.10.00 for Maximum Daily Morphine Equivalent apply.Greater than 20 mg per day
Use with another opioid: Calculate MME as part of the prior authorization criteria. If the dose exceeds 120 MME per day, the criteria under Policy 65.10.00 for Maximum Daily Morphine Equivalent apply.Greater than 120 MME per day

Continuation therapy

Reauthorization requests may be approved for 12 months when all of the following are met:

Continuation requirements

Patient continues to meet all initial criteria.
Patient demonstrates clinically meaningful improvement in pain and/or function.

Billing and Coding

Methadone HCPCS CodesHCPCS

S0109	Methadone, oral, 5 mg
J1230	Injection, methadone hcl, up to 10 mg

Methadone dose and quantity limit

DrugMethadone

Daily dose and quantity limit20 mg per day

Doses above the limitRequire documentation of clinical benefit at previous doses and a clear clinical rationale for further dose increases

Combined opioid maximum daily MME threshold

Applies whenMethadone is used in combination with any other opioid prescription

Combined opioid thresholdGreater than 120 MME per day

Related criteriaThe maximum daily Morphine Equivalent criteria under Policy 65.10.00 apply

Provider Actions and Documentation

Prior Authorization

Prior Authorization Required

Methadone prescriptions require prior authorization before approval. Expedited authorization codes 85000000540 and 85000000541 do not apply to methadone products.

Step Therapy

Preferred-Drug Requirement

Non-preferred analgesic opioid agonists require applicable preferred-drug trials before authorization.

Document an inadequate response or documented intolerance due to a severe adverse reaction or contraindication to at least two preferred agents.
If only one preferred agent is available in the class, document an inadequate response to that one agent.
New-to-market drugs in the class are non-preferred and subject to these criteria; consult the current Apple Health Preferred Drug List.

Documentation Required

Initial Chronic-Pain Documentation

For an initial prescription for chronic non-cancer pain, submit documentation showing that one applicable pathway is met.

Continuation of current methadone therapy for severe chronic pain; or
For non-cancer pain, trial and failure of all generic long-acting opioids within the previous 12 months, unless contraindicated or associated with intolerable adverse effects; or
For cancer pain, hospice, palliative care, or end-of-life care, trial and failure of two preferred long-acting opioids within the previous 12 months, unless contraindicated or associated with intolerable adverse effects.

Documentation Required

Documentation for Doses Above 20 mg per Day

For doses greater than 20 mg per day, document clinical benefit at previous doses and a clear clinical rationale that the patient is likely to benefit from further dose increases.

The criteria under Policy 65.10.00 for Maximum Daily Morphine Equivalent (MME) apply.
When methadone is used with another opioid prescription, calculate total MME as part of the prior authorization review.
If the dose exceeds 120 MME per day, the Policy 65.10.00 Maximum Daily MME criteria apply.

Documentation Required

Reauthorization Documentation

Reauthorization requests may be approved for 12 months only when the patient continues to meet all initial criteria and demonstrates clinically meaningful improvement.

Document continued satisfaction of the applicable initial clinical criteria.
Document meaningful improvement in pain and/or function.

Denial Risk

Failure to Meet Prior Authorization Criteria

A request may be denied when required prior authorization is missing or when the applicable clinical criteria are not met.

Methadone must be approved through prior authorization or an applicable exception before coverage.
Denial may result when required clinical documentation is absent or when the patient does not meet the applicable initial criteria.

Denial Risk

Insufficient Reauthorization Evidence

Reauthorization is at risk of denial when the record does not establish continued eligibility or meaningful treatment benefit.

Failure to document that all initial criteria continue to be met may result in denial.
Failure to demonstrate clinically meaningful improvement in pain and/or function may result in denial.

Clinical Background

Initial Methadone Therapy

Initial methadone therapy

Initial methadone therapy requires prior authorization and documentation that all of the following are met:

Methadone prescription has prior authorization.
Methadone may be considered medically necessary when approved under the clinical criteria or an applicable exception.
ALL of the following
- ONE applicable pathway
  - Continuation of current methadone therapy for severe chronic pain.
  - For non-cancer pain, trial and failure of all generic long-acting opioids within the last 12 months, unless contraindicated or the patient experienced intolerable adverse effects.Within the last 12 months
  - For cancer pain, or for patients in hospice, receiving palliative care, or receiving end-of-life care, trial and failure of two preferred long-acting opioids within the last 12 months, unless contraindicated or the patient experienced intolerable adverse effects.Two preferred long-acting opioids within the last 12 months

Preferred Drug Step Therapy

Step	Requirement	Exception
1	For a non-preferred agent in the analgesic opioid agonist class, document an inadequate response or intolerance due to a severe adverse reaction or contraindication to at least two preferred agents.	If only one preferred agent exists in the class, document an inadequate response or intolerance to that one preferred agent.