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    OpenPayerPolicy UpdatesClinical/Medical PolicyWellpoint Opioid Prior Auth Coverage | OpenPayer
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    CurrentWellpointPolicy WEBPMD-0077-17

    Opioid Prescribing Policies

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    This policy governs opioid prescribing requirements for Maryland Medicaid Fee-for-Service and Medicaid Managed Care Organization beneficiaries. It establishes prior authorization, quantity, monitoring, screening, naloxone, and referral expectations for specified opioid therapies and higher opioid doses.

    Policy Summary
    PayerWellpoint
    PolicyOpioid Prescribing Policies
    Policy CodePolicy WEBPMD-0077-17
    Change TypeNo material clinical or coverage change
    Effective DateJuly 1, 2017
    Next Review DateN/A
    Key ActionObtain prior authorization every 6 months for long-acting opioids, fentanyl products, methadone for pain, and opioid prescriptions exceeding 90 MME per day.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    90 MME/dayPrior authorization threshold
    30 daysStandard quantity limit
    6 monthsAuthorization renewal
    4Required attestations

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    50 MME/day
    Naloxone risk threshold

    Coverage Criteria

    Opioid prior authorization

    Prior authorization is required when any of the following applies:

    Authorization-triggering opioid therapy or dose

    • The prescription is for a long-acting opioid.
    • The prescription is for a fentanyl product.
    • The prescription is for methadone prescribed for pain.
    • The opioid regimen results in more than 90 MME per day.>90 MME/day

    Authorization documentation

    Prior authorization requires all of the following attestations:

    Required monitoring and risk-mitigation attestations

    • The provider reviewed the patient's Controlled Dangerous Substance prescriptions in the Prescription Drug Monitoring Program (PDMP).
    • A Patient-Provider agreement was reviewed or established.
    • The patient was screened with random urine drug screen(s) before and during treatment.
    • A naloxone prescription was given or offered to the patient or the patient's household member.

    Patients with cancer, sickle cell anemia, or hospice status are excluded from the prior authorization process. These patients should nevertheless be maintained on the lowest effective opioid dose for the shortest required duration to minimize the risk of harm.

    Dose and Threshold Reference

    Prior authorization dose threshold
    Threshold>90 MME per day
    Applies toAny opioid prescription that results in a patient exceeding 90 MME per day
    Authorization intervalPrior authorization must be obtained every 6 months
    Naloxone risk-factor dose threshold
    Naloxone risk thresholdOver 50 MME
    Recommended actionPrescribe naloxone when this risk factor is present
    Additional risk factorsHistory of substance use disorder; concurrent opioids and benzodiazepines or non-benzodiazepine sedative hypnotics; or drug-using friends or family

    Provider Actions and Authorization Requirements

    Prior Authorization

    Six-Month Opioid Authorization

    Obtain prior authorization every 6 months when prescribing long-acting opioids, fentanyl products, methadone for pain, or any opioid regimen exceeding 90 morphine milliequivalents (MME) per day.

    • The six-month renewal interval applies to each of these authorization-triggering therapies or dose levels.
    Documentation Required

    Prior Authorization Attestations and Screening

    Each prior authorization submission must include attestations documenting the provider’s review of the patient’s controlled dangerous substance (CDS) prescriptions in the Prescription Drug Monitoring Program (PDMP), a Patient-Provider agreement, screening with random urine drug screen(s) before and during treatment, and that naloxone was given or offered to the patient or a household member.

    • Screen patients for substance use disorder with a standardized tool before prescribing an opiate or other controlled substance; SBIRT is an example.

    Clinical Background

    The policy recommends non-opioid treatments as first-line therapy for chronic pain, including NSAIDs, duloxetine, topical diclofenac, and selected non-pharmacological treatments such as physical therapy. Opioid therapy should be prescribed cautiously, with benefits and risks reassessed when considering doses of at least 50 MME/day and doses of at least 90 MME/day avoided unless carefully justified.

    Definitions

    SBIRT
    AbbreviationSBIRT
    Full termScreening, Brief Intervention and Referral to Treatment
    PurposeAn evidence-based practice used to identify, reduce and prevent problematic use, abuse and dependence on alcohol and drugs
    Naloxone
    DefinitionNaloxone is an opioid antagonist used to reverse opioid overdose
    Prescribing considerationProviders are encouraged to prescribe naloxone when specified overdose-risk factors are present
    Dose-related risk factor

    Initial Authorization Criteria

    Initial opioid authorization

    Initial authorization is required when any of the following applies:

    Initial opioid authorization trigger

    • The prescribed therapy is a long-acting opioid.
    • The prescribed therapy is a fentanyl product.
    • The prescribed therapy is methadone for pain.
    • The opioid regimen results in more than 90 MME per day.>90 MME/day

    Continuation Authorization Criteria

    Continuation authorization

    For therapies requiring authorization, authorization must be renewed every 6 months:

    Six-month continuation authorization

    • Continuation of a long-acting opioid requires a new prior authorization.Every 6 months
    • Continuation of a fentanyl product requires a new prior authorization.Every 6 months
    • Continuation of methadone for pain requires a new prior authorization.Every 6 months

    First-Line Treatment

    StepRequirementExamples
    1Non-opioids are considered first-line treatment for chronic pain.NSAIDs; duloxetine for chronic pain; topical diclofenac; and selected non-pharmacological treatments, such as physical therapy.

    Quantity and Dose Limits

    All opioids
    Drug categoryAll opioids
    Standard quantity period30 days
    Dose limitAt or below 90 MME per day
    Coverage implicationQuantities exceeding the standard 30-day limit or doses above 90 MME per day may not be covered without authorization
    Policy Summary
    PayerWellpoint
    PolicyOpioid Prescribing Policies
    Policy CodePolicy WEBPMD-0077-17
    Change TypeNo material clinical or coverage change
    Effective DateJuly 1, 2017
    Next Review DateN/A
    Key ActionObtain prior authorization every 6 months for long-acting opioids, fentanyl products, methadone for pain, and opioid prescriptions exceeding 90 MME per day.
    SourceLink
    On This Page
    Coverage CriteriaDose and Threshold ReferenceProvider Actions and Authorization RequirementsClinical BackgroundDefinitionsInitial Authorization CriteriaContinuation Authorization CriteriaFirst-Line TreatmentQuantity and Dose Limits
  1. Use caution for patients with current or prior substance use disorder and refer identified patients to a substance use treatment program.
  2. SBIRT is a billable Medicaid service.
    3. Prior Authorization

    Prior Authorization Required

    Prior authorization is required for long-acting opioids, fentanyl products, methadone for pain, and any opioid prescription that results in a patient exceeding 90 MME per day. Non-opioids are first-line treatment for chronic pain, and providers should consider available alternatives before opioid therapy.

    • Available Medicaid alternatives include NSAIDs, duloxetine for chronic pain, diclofenac topical, and certain first-line non-pharmacological treatments such as physical therapy.
    • Patients with cancer, sickle cell anemia, or in hospice are excluded from the prior authorization process, but should remain on the lowest effective opioid dose for the shortest required duration.
    • HealthChoice MCOs may implement additional requirements or limitations beyond the State policy.
    Billing Rule

    Quantity and Dose Limits

    All opioids are subject to a standard 30-day quantity limit at or below 90 MME per day. Providers should use caution at any opioid dosage, reassess individual benefits and risks when considering doses of 50 MME/day or more, and avoid doses of 90 MME/day or more unless the decision to titrate is carefully justified.

    • Opioid prescriptions exceeding 90 MME/day require prior authorization.
    • Use the lowest effective dose for the shortest required duration, including for patients excluded from prior authorization.
    High-dose or cumulative opioid prescriptions resulting in over 50 MME
    MME
    AbbreviationMME
    Full termMorphine milliequivalents
    UseA common morphine-equivalent measure for assessing total daily opioid exposure
    Continuation of an opioid regimen above 90 MME per day requires a new prior authorization.Every 6 months; above 90 MME/day