Opioid Prior Authorization Requirements

Opioid Prior Authorization Form

IMPORTANT INFORMATION ABOUT PRESCRIBING OPIOIDS FOR MEDSTAR FAMILY CHOICE MEMBERS

Early Refill Requests
“Early” opioid refills will no longer be covered by MedStar Family Choice, effective 1/1/2019
Beginning 1/1/2019, MedStar Family Choice will not authorize early refills of controlled medications. Specifically, MedStar Family Choice will not approve early refills, override Managed Drug Limitations (MDL), replace lost/stolen medications, or provide early refills for travel for controlled medications. Exceptions may be granted if a member is receiving controlled medication(s) for cancer treatment, sickle cell disease, or is in hospice/receiving palliative care.

Prior Authorization
Prior authorization will be required for:

  • Prescriptions > 50 MME/day or more than 7 days for an opioid naïve patient (no opioids taken in the previous 90 days or one ≤ 50 MME per day, ≤ 7 day prescription taken in the previous 90 days) as described in Section I

  • Opioid experienced patients as described in Section II

Section I: Opioid naïve patients

(defined as: no opioids in the previous 90 days or one fill of ≤ 50 MME per day for ≤ 7 days prescription taken in the previous 90 days)

A “new” prescription means that a patient has not had an opioid medication filled under MedStar Family Choice in the preceding 90 days or had one short-acting opioid at ≤ 50 morphine equivalents per day for 7 or fewer days in previous 90 days. New prescriptions for more than 7-days’ supply or greater than 50 MME per day will require prior authorization.

It is our hope that limiting opioid quantities to a 7-day supply will discourage abuse, both by our patients and by the community at large. This change is also consistent with Medicare policy (effective 2019) which limits opioid naïve patients to a 7-day supply.

According to the CDC 2016 Guidelines for Prescribing Opioids, “When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.”

Examples of a typical 3-day supply and a 7-day supply of frequently prescribed opioids are below:

Medication 3-day supply quantity* 7-day supply quantity*
(maximum allowable)
Hydromorphone Tab 2mg 18 tablets 42 tablets
Morphine Sulfate Tab 15mg 18 tablets 42 tablets
Oxycodone Solution 5mg/5mL 180 mL 420 mL
Oxycodone Tab 5mg 18 tablets 42 tablets
Tramadol 18 tablets 42 tablets

*Quantities are based on starting dose recommendations in the respective FDA package inserts for each medication.

Please contact MedStar Family Choice at 800-905-1722, option 2, for prior authorization of new opioid prescriptions that exceed the limits. 

MedStar Family Choice strongly encourages you to prescribe the least amount of opioid at the lowest dose possible to achieve pain relief goals.

Section II: Opioid experienced patients

The Maryland Department of Health (MDH) and the nine Medicaid Managed Care Organizations (MCOs) in Maryland’s HealthChoice Program require prior authorization for the following medications:

  • Long-acting opioids

  • Fentanyl products

  • Methadone for pain

  • Any opioid prescription (or combination of opioid prescriptions) that results in a patient exceeding 90 morphine milliequivalents (MME) per day. Instructions on calculating MME are available at the CDC website.

For the sake of illustration of what constitutes 90 MME, the following is a list of daily doses of commonly prescribed opioids that equal 90 MME/day:

Fentanyl 112.5 mcg/day
Hydrocodone 90 mg/day
Hydromorphone 22.5 mg/day
Morphine 90 mg/day
Oxycodone 60 mg/day
Oxymorphone 30 mg/day

The following are examples of common prescriptions that equal 90 MME/day:

oxycodone 20 mg tid
methadone 20 mg qd
hydrocodone 10/325, 3 tabs tid

Additionally, some smaller doses of immediate release medications will require prior authorization at less than 90 MME. The decision to limit these medications was made by the Maryland Department of Health in an effort to decrease the number of pills available for diversion. These medications are as follows:

 Medication Max per 30 days Unit
 Codeine compounds (all) 1,000 mL
180  tablet/capsule
 Hydrocodeine compounds (all)  2,750  mL
 180  tablet/capsule
 Hydromorphone
(1 mg/mL solution, 2 mg tablet, 3 mg suppository)		  675  mL
 180  tablet/capsule
 Morphine
(5 mg suppository, 10 mg/5mL solution, 10 mg suppository)		  1,350  mL
 180  suppository
 Oxycodone compounds
(2.5 mg, 5 mg, 7.5 mg of all formulations)		  1,800  mL
 180   tablet/capsule
 Tramadol
(100 mg, 200 mg)		  180  tablet/capsule

In order to receive prior authorization, prescribers must attest to the following:

  • Prescriber has reviewed controlled substance prescriptions in a Prescription Drug Monitoring Program (ex: CRISP—Chesapeake Regional Information System for our Patients).

  • Prescriber will utilize random urine drug screens.

  • Prescriber has provided or offered a prescription for naloxone to the patient or patient’s household if the patient:

    • Has a history of substance use disorder

    • Requires more than 50 MME (for example, more than Fentanyl 62.5 mcg/72 hours, hydrocodone 50 mg/day, hydromorphone 12.5 mg/day, morphine 50 mg/day, oxycodone 33 mg/ day, and oxymorphone 16 mg/day)

    • Is prescribed both opioids and benzodiazepines

    • Is prescribed other sedative hypnotics

    • Or for any other reason deemed clinically appropriate

  • Prescriber and patient have signed a Pain Management/Opioid Treatment Agreement/Contract and it is stored in the patient’s medical record

In the coming months, MDH will be offering further training on the new opioid prescribing policies outlined here. We urge you to evaluate patients impacted by these policy changes, and where appropriate, step them down to lower doses, or utilize non-opioid first line treatments.

Information current as of: