CurrentWellpointPolicy MDCRX-0001-18

Opioid Analgesics

Customize your policy alerts

Sign up for wellpoint Policy MDCRX-0001-18 alerts

Get alerted when Policy MDCRX-0001-18 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Maryland Medicaid pharmacy coverage, quantity and duration limits, age requirements, and prior authorization for short-acting, long-acting, tramadol-containing, and codeine-containing opioid analgesics.

Policy Summary

PayerWellpoint

PolicyOpioid Analgesics

Policy CodePolicy MDCRX-0001-18

Change TypeNo material change

Effective DateFebruary 1, 2018

Next Review DateN/A

Key ActionSubmit prior authorization for long-acting opioids, opioid use above 90 MME per day, acute-pain duration limits, and age-based tramadol or codeine requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>90 MME/dayDose threshold

7 daysAcute-pain limit

30 daysQuantity period

18 yearsLong-acting opioid age

6 monthsMaintenance approval

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.

CurrentWellpointPolicy MDCRX-0001-18

Opioid Analgesics

Customize your policy alerts

Sign up for wellpoint Policy MDCRX-0001-18 alerts

Get alerted when Policy MDCRX-0001-18 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerWellpoint

PolicyOpioid Analgesics

Policy CodePolicy MDCRX-0001-18

Change TypeNo material change

Effective DateFebruary 1, 2018

Next Review DateN/A

Key ActionSubmit prior authorization for long-acting opioids, opioid use above 90 MME per day, acute-pain duration limits, and age-based tramadol or codeine requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>90 MME/dayDose threshold

7 daysAcute-pain limit

30 daysQuantity period

18 yearsLong-acting opioid age

6 monthsMaintenance approval

1 yearException approval

Opioid Coverage Criteria

High-dose opioid and quantity-limit approval

Covered when the request is subject to the high-dose and quantity-limit review and either a qualifying condition is documented or all prescriber safety attestations are completed.

High-dose and quantity-limit request

The request is for an opioid analgesic exceeding 90 MME per day and subject to the 30-day quantity limit.>90 MME/day and 30-day quantity limit
ONE of the following approval pathways
- Qualifying condition or care setting: The individual has cancer-related pain or is actively undergoing cancer therapy; terminal illness with palliative or end-of-life care; sickle cell disease; or current residence in a long-term-care facility.
  Provide the applicable diagnosis or facility documentation.
- Prescriber safety attestations: The prescriber has reviewed Controlled Dangerous Substance prescriptions in PDMP/CRISP; the patient has had or will have random urine drug screens before and during treatment; naloxone was provided or offered to the patient or household; a patient-prescriber pain management or opioid treatment agreement is signed and in the medical record; and the prescriber certified that opioid-treatment benefits outweigh risks.

Short-acting opioid acute-pain duration

Requests exceeding the standard acute-pain limits may be approved when an exception diagnosis is documented. Other requests require review.

Acute-pain exception diagnosis: The individual has cancer-related pain or is actively undergoing cancer treatment; a terminal condition with palliative or end-of-life care; or sickle cell anemia.>7 days' supply of a short-acting opioid for acute pain, or >14 days' supply in 30 days for an individual not consistently receiving opioids

Individuals consistently receiving opioids are those with prescribed daily use for 80 of the past 90 days based on prescription dispensing history. Other requests exceeding the limits are reviewed.

Long-acting opioid approval

Covered when all required long-acting opioid criteria are met.

Long-acting opioid medical necessity and safety

Qualifying condition or chronic severe pain pathway
- Qualifying condition or care setting: The individual has cancer-related pain or is actively undergoing cancer therapy; terminal illness with palliative or end-of-life care; sickle cell disease; or current residence in a long-term-care facility.
- Chronic severe pain and alternative-treatment rationale: The individual has pain severe enough to require daily, around-the-clock, long-term opioid treatment and has an inadequate response to alternative treatment options, alternative treatment options would otherwise be inadequate to provide sufficient pain management, or a contraindication to non-opioid analgesics.
  Examples of contraindications include active ulcer disease or gastrointestinal bleeding and renal failure.
Age and opioid exposure requirements:

Non-preferred long-acting opioid exception

A non-preferred long-acting opioid requires the standard long-acting opioid criteria plus one additional exception pathway.

Non-preferred long-acting opioid requirements

All applicable standard long-acting opioid criteria are met, including medical necessity, age and opioid-exposure requirements, initial or continued therapy requirements, and risk-management requirements.
ONE additional exception pathway
- Preferred-agent trials: The individual has tried two preferred long-acting agents and had an inadequate response or intolerance to both.
  Preferred agents are morphine sulfate ER tablets, methadone, and generic fentanyl patch. Samples, coupons, and discount cards do not count as trials.
- Stable maintenance: The individual has completed titration and is already maintained on a stable dose of the requested drug.

Brand Duragesic or brand fentanyl patch

Brand Duragesic or brand fentanyl patch requests require the standard applicable long-acting opioid criteria plus one additional pathway.

Brand fentanyl patch requirements

All applicable standard long-acting opioid criteria are met.
ONE additional brand-exception pathway
- Preferred-agent trial: The individual has tried a preferred oral long-acting opioid and had an inadequate response or intolerance.
  Preferred oral agents are morphine sulfate tablets (generic MS Contin) and methadone.
- Stable maintenance: The individual is already maintained on the requested brand Duragesic or brand fentanyl patch.

Tramadol and codeine age approval

Age-based approval criteria apply to tramadol- and codeine-containing products.

Tramadol approval: The individual is 18 years of age or older, or is 12 years of age or older and is being treated for a pain condition other than postsurgical removal of the tonsils and/or adenoids.Age 18+, or age 12+ for non-tonsillectomy/adenoidectomy pain

Codeine approval: The individual is 12 years of age or older.Age 12+

Long-acting opioids are not approved for as-needed analgesic use. Requests must be for an appropriate scheduled treatment plan consistent with the long-acting opioid criteria.

Long-acting opioid requests are not approved when the individual has significant respiratory depression, acute or severe bronchial asthma or hypercarbia, or known or suspected paralytic ileus. These conditions are contraindications to coverage.

Tramadol is contraindicated for pain after tonsillectomy or adenoidectomy in individuals younger than 18 years and for pain treatment in children younger than 12 years. Codeine is contraindicated for pain or cough in children younger than 12 years.

Initial Long-Acting Opioid Therapy

Initial long-acting opioid therapy

Initial long-acting opioid therapy requires that the individual is not opioid naïve and that the applicable medical-necessity and safety requirements are met.

Opioid status
- The individual is currently receiving a short-acting opioid analgesic, including opioid analgesia received as an inpatient for postsurgical pain.
- The individual is transitioning from one long-acting opioid analgesic to another.
The applicable long-acting opioid medical-necessity, age, risk-management, and treatment-goal criteria are met.

Long-Acting Opioid Maintenance Therapy

Long-acting opioid maintenance therapy

Continued long-acting opioid therapy may be approved when meaningful benefit and ongoing safety management are documented.

Continuation of long-acting opioid therapy

Long-acting opioid therapy has provided meaningful improvement in pain and/or function compared with baseline.
The prescriber has discussed opioid-treatment risks with the individual and defined clear treatment goals as part of the overall plan.
The prescriber has reviewed controlled-substance prescriptions in PDMP/CRISP, completed or planned random urine drug screens, provided or offered naloxone, obtained a signed patient-prescriber pain management or opioid treatment agreement in the medical record, and certified that treatment benefits outweigh risks.
Maintenance authorization is required for each additional 6 months.

Thresholds, Durations, and Age Requirements

High-dose opioid threshold

Threshold>90 milligram morphine equivalents (MME) per day

Applies toAll opioid agents, including short-acting and long-acting opioids

Review contextUsed with the 30-day quantity limit for prior authorization review

Opioid quantity limit

Limit period30-day quantity limit

Applies toAll opioid agents, including short-acting and long-acting opioids

Combined thresholdApplies to opioid use exceeding 90 MME per day

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Scope and Duration

Prior authorization applies to long-acting opioid analgesics, quantity limits apply to long- and short-acting opioids, and tramadol- and codeine-containing products require age-based authorization. Initial approvals are generally limited to 3 months, with an additional prior authorization required for each subsequent 6-month maintenance period.

Individuals with cancer, sickle cell anemia, those receiving hospice care, or residents of a long-term care facility are excluded from prior authorization and quantity limitations; approve for 1 year.

Prior Authorization

High-Dose Opioid Authorization

Requests for any short- or long-acting opioid exceeding 90 MME per day and the 30-day quantity limit may be approved when the individual has a qualifying condition or care setting, or when the prescriber completes all required opioid-safety attestations.

Qualifying circumstances: cancer-related pain or active cancer treatment, terminal illness with palliative or end-of-life care, sickle cell disease, or residence in a long-term care facility.
The prescriber must attest to PDMP/CRISP review, random urine drug screening, naloxone provision or offer, a signed pain-management agreement in the medical record, and that treatment benefits outweigh risks.

Opioid Analgesic Safety Context

This policy addresses opioid analgesic safety risks, including addiction, abuse, misuse, respiratory depression, accidental exposure, overdose, and neonatal opioid withdrawal syndrome. Long-acting opioid therapy requires assessment before prescribing and ongoing monitoring, particularly when treatment is initiated or doses are increased. The policy also incorporates pediatric safety concerns for tramadol- and codeine-containing products, including the risk of slowed or difficult breathing and death in younger children.

Policy Definitions

Consistently receiving opioids

DefinitionPrescribed daily opioid use for 80 out of the past 90 days

Verification sourcePrescription dispensing history

Policy useDefines individuals consistently receiving opioids for short-acting opioid duration and quantity review

Not opioid naïve

Current useCurrently receiving a short-acting opioid analgesic

Inpatient exposureIncludes opioid analgesia received as an inpatient for postsurgical pain

Transition status

Preferred-Agent Requirements

Step	Preferred agent(s)	Requirement before non-preferred therapy
1	Morphine sulfate ER tablets (generic MS Contin), methadone, or generic fentanyl patch (generic Duragesic)	Document a trial of two preferred long-acting agents with inadequate response or intolerance. Samples, coupons, and discount cards do not count as trials. Exceptions may apply for stable maintenance, unacceptable preferred agents due to a clinical situation, need for an abuse-deterrent formulation, or concern for abuse or dependence with pure opioid agents.

Step	Preferred agent(s)	Requirement before brand therapy
1	Preferred oral morphine sulfate tablets (generic MS Contin) or methadone	Document a trial of one preferred oral long-acting opioid with inadequate response or intolerance. Exceptions may apply when the individual is already maintained on the requested brand Duragesic or brand fentanyl patch, or when preferred oral agents are unacceptable because of hypersensitivity or difficulty swallowing tablets or capsules.

Opioid Quantity and Duration Limits

Opioid quantity limits

Dose threshold>90 MME per day

Quantity period30-day quantity limit

Affected agentsAll short-acting and long-acting opioid agents

Short-acting opioid limits

Acute-pain durationMore than 7 days' supply requires approval

30-day quantityMore than 14 days' supply in 30 days requires review for individuals not consistently receiving opioids

ExceptionsCancer-related pain or active cancer treatment, terminal illness with palliative or end-of-life care, or sickle cell anemia

Policy Summary

PayerWellpoint

PolicyOpioid Analgesics

Policy CodePolicy MDCRX-0001-18

Change TypeNo material change

Effective DateFebruary 1, 2018

Next Review DateN/A

Key ActionSubmit prior authorization for long-acting opioids, opioid use above 90 MME per day, acute-pain duration limits, and age-based tramadol or codeine requests.

SourceLink

On This Page

The individual is 18 years of age or older, unless the request is for OxyContin or a fentanyl transdermal patch and the applicable younger-age and prior-opioid-dose requirements are met.

Age 18+ generally; OxyContin age 11+ with at least 20 mg/day oral oxycodone or equivalent; fentanyl patch age 2+ with specified opioid tolerance

Initial or continued therapy

Initial therapy: The individual is not opioid naïve because they are currently receiving a short-acting opioid, including inpatient opioid analgesia for postsurgical pain, or are transitioning from one long-acting opioid analgesic to another.
Continued therapy: Long-acting opioid therapy has provided meaningful improvement in pain and/or function compared with baseline.

Risk management and treatment planning: The prescriber has discussed opioid-treatment risks with the individual, defined clear treatment goals, reviewed controlled-substance prescriptions in PDMP/CRISP, arranged random urine drug screens, provided or offered naloxone, obtained a signed patient-prescriber treatment agreement in the medical record, and certified that treatment benefits outweigh risks.

Clinical unacceptability of preferred agents: Preferred long-acting opioids are not acceptable because of a concomitant clinical situation, such as known hypersensitivity to an ingredient that is not also present in the requested non-preferred agent.

Abuse-deterrent formulation: The individual requires an abuse-deterrent formulation because of a personal, family-member, or household resident history of substance abuse disorder.

Buprenorphine exception: There is concern for abuse or dependence with pure opioid agents supporting use of Butrans or Belbuca.

Clinical unacceptability of preferred agents:

Preferred oral long-acting opioids are not acceptable because of a concomitant clinical situation, such as known hypersensitivity to an ingredient that is not also present in the requested brand patch or difficulty swallowing tablets or capsules.

Short-acting opioid acute-pain duration

Standard durationGreater than 7 days' supply of a short-acting opioid for acute pain

Required actionRequires approval or an applicable exception

Exception conditionsCancer-related pain or active cancer treatment, terminal illness with palliative or end-of-life care, or sickle cell anemia

Short-acting opioid 30-day quantity

Quantity thresholdGreater than 14 days' supply in 30 days

Applies toIndividuals who are not consistently receiving opioid analgesics

Required actionRequests are reviewed unless an applicable exception is documented

Consistent opioid exposure

DefinitionPrescribed daily opioid use for 80 out of the past 90 days

BasisPrescription dispensing history

RelevanceDetermines whether acute-pain duration and quantity limits apply to an individual not consistently receiving opioids

OxyContin age and prior opioid dose

Minimum age11 years of age or older

Prior opioid exposureAlready receiving and tolerating at least 20 mg of oral oxycodone daily or its equivalent

ProductOxyContin

Duragesic age and prior opioid dose

Minimum age2 years of age or older

Prior opioid exposureAlready receiving at least 60 mg/day oral morphine, 30 mg/day oral oxycodone, 8 mg/day oral hydromorphone, or an equianalgesic dose of another opioid

ProductFentanyl transdermal patch, including Duragesic

Tramadol minimum ages

General minimum age18 years of age or older

Alternative age pathway12 years of age or older for pain conditions other than postsurgical removal of the tonsils and/or adenoids

Prohibited indicationPain after tonsillectomy or adenoidectomy in individuals younger than 18 years

Codeine minimum age

Minimum age12 years of age or older

Applies toCodeine-containing agents

Pediatric restrictionCodeine is contraindicated for pain or cough in children younger than 12 years

Prior Authorization

Long-Acting Opioid Authorization

Long-acting opioid requests may be approved when the individual has a qualifying diagnosis or care setting, severe pain requiring daily around-the-clock long-term opioid treatment, and appropriate prior-treatment or contraindication documentation.

Qualifying circumstances include cancer-related pain or active cancer treatment, terminal illness with palliative or end-of-life care, sickle cell disease, or residence in a long-term care facility.
Document inadequate response to alternatives, inadequacy of alternatives for sufficient pain control, or contraindications to non-opioid analgesics.

Prior Authorization

Tramadol Age Authorization

Tramadol-containing products may be authorized for individuals age 18 or older, or for individuals age 12 or older when treating pain other than pain following surgical removal of the tonsils and/or adenoids.

Do not approve tramadol for pain after tonsillectomy and/or adenoidectomy in individuals younger than 18 years or for pain in individuals younger than 12 years.

Prior Authorization

Codeine Age Authorization

Codeine-containing products may be authorized for individuals age 12 or older.

Codeine is contraindicated for treatment of pain or cough in children younger than 12 years.

Step Therapy

Non-Preferred Long-Acting Opioid Step Therapy

A non-preferred long-acting opioid, other than a single-source brand fentanyl patch or brand Duragesic, requires documentation of preferred-agent use or a qualifying exception in addition to the standard long-acting opioid criteria.

Document an inadequate response or intolerance to two preferred long-acting agents: morphine sulfate extended-release tablets, methadone, or generic fentanyl patch.
Alternative pathways include completed titration with stable maintenance on the requested drug, unacceptable preferred agents because of a concomitant clinical situation, or a documented need for an abuse-deterrent or buprenorphine formulation.

Step Therapy

Brand Fentanyl Step Therapy

Brand fentanyl patches, including brand Duragesic, require a trial of a preferred oral long-acting opioid or documentation of an applicable exception.

Preferred oral agents are morphine sulfate extended-release tablets (generic MS Contin) and methadone.
Document inadequate response or intolerance to a preferred oral agent, stable maintenance on the requested brand patch, or an exception such as hypersensitivity or difficulty swallowing tablets or capsules.

Documentation Required

High-Dose and Quantity-Limit Documentation

For requests exceeding 90 MME per day or the 30-day quantity limit, submit documentation of a qualifying diagnosis or care setting, or complete exception documentation supporting the requested opioid therapy.

Provide a cancer diagnosis or terminal diagnosis when applicable; document sickle cell disease or long-term care residence when applicable.
For the prescriber-attestation pathway, document PDMP/CRISP review, random urine drug screens, naloxone provision or offer, a signed treatment agreement, and a benefit-versus-risk certification.

Documentation Required

Opioid Safety Documentation

Document opioid-safety safeguards before and during treatment, including controlled-substance review, drug screening, naloxone counseling or access, a treatment agreement, and the prescriber's benefit-versus-risk assessment.

Review controlled-substance prescriptions in the PDMP (CRISP).
Perform or plan random urine drug screens before and during treatment.
Provide or offer naloxone to the patient or household and retain the signed pain-management/opioid-treatment agreement in the medical record.

Documentation Required

Long-Acting Opioid Medical Necessity

Long-acting opioid medical necessity requires documentation of a diagnosis and pain severe enough to require daily, around-the-clock, long-term opioid treatment.

Also document a qualifying diagnosis or care setting: cancer-related pain or active cancer treatment, terminal illness with palliative or end-of-life care, sickle cell disease, or long-term care residence.
Explain why alternatives are inadequate or contraindicated.

Documentation Required

Initial and Continuation Documentation

For initial therapy, document that the individual is not opioid-naïve. For continuation therapy, attest that long-acting opioid treatment has produced meaningful improvement in pain and/or function compared with baseline.

Initial therapy documentation may show current use of a short-acting opioid, including inpatient postoperative opioid use, or transition from another long-acting opioid.
Continuation requests should include current opioid status, pain or functional improvement, defined treatment goals, and required safety documentation.

Step Therapy

Preferred-Agent Exception Documentation

When requesting a preferred-agent exception, document prior trials and the reason preferred therapy cannot be used or is inadequate.

Document inadequate response or intolerance to the required preferred agents; medication samples, coupons, and discount cards do not count as trials.
Exceptions may include stable maintenance on the requested drug, clinically unacceptable preferred agents, hypersensitivity, difficulty swallowing, or a documented need for an abuse-deterrent or buprenorphine product.

Denial Risk

Long-Acting Opioid Contraindications and PRN Use

Long-acting opioids are not approved for as-needed analgesic use and are subject to specified safety-related denial conditions.

Do not approve requests for as-needed use.
Do not approve when the individual has significant respiratory depression, acute or severe bronchial asthma or hypercarbia, or known or suspected paralytic ileus.

Step Therapy

Non-Preferred Long-Acting Opioid Requirements

A non-preferred long-acting opioid requires a qualifying trial of preferred therapy or a documented exception, in addition to meeting the standard long-acting opioid criteria.

Document an inadequate response or intolerance to two preferred long-acting agents, or document stable maintenance on the requested drug.
An exception may be based on a concomitant clinical situation making preferred agents unacceptable, including qualifying hypersensitivity.

Step Therapy

Brand Fentanyl Patch Requirements

Brand Duragesic or brand fentanyl patches require a qualifying trial of a preferred oral long-acting opioid or documentation of an applicable exception.

Preferred oral agents are generic morphine sulfate extended-release tablets (MS Contin) and methadone.
Document inadequate response or intolerance, stable maintenance on the requested brand patch, hypersensitivity, or difficulty swallowing tablets or capsules.

Billing Rule

Acute-Pain Duration and Quantity Limits

For individuals who are not consistently receiving opioids, requests for more than a 7-day supply of a short-acting opioid for acute pain may be approved for specified qualifying conditions. Other requests exceeding 7 days, or exceeding 14 days in 30 days, will be reviewed.

Qualifying conditions are cancer-related pain or active cancer treatment, terminal illness with palliative or end-of-life care, or sickle cell anemia.
Consistent opioid use means prescribed daily use for at least 80 of the previous 90 days based on dispensing history.

Denial Risk

Pediatric Opioid Age Restrictions

Apply pediatric age restrictions to tramadol- and codeine-containing opioid products before submitting an authorization request.

Tramadol: age 18 or older, or age 12 or older for pain other than post-tonsillectomy/adenoidectomy pain.
Codeine: age 12 or older for pain or cough.

Includes transitioning from one long-acting opioid analgesic to another

Abuse-deterrent formulation

DefinitionA long-acting opioid formulation intended to reduce abuse potential

Identified productsEmbeda ER, Hysingla ER, MorphaBond, Xtampza ER, and Troxyca ER

Qualifying contextMay support coverage when there is a personal, family, or household history of substance abuse disorder