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Opioid Prior Authorization Requirements

The Maryland Department of Health (MDH) and the eight Medicaid Managed Care Organizations (MCOs) in Maryland’s HealthChoice Program will implement opiate prescribing policies no later than July 1, 2017 for all Medicaid Patients, including those served by a MCO or Medicaid Fee-For-Service. These policy changes are being made in light of the increasing volume of opioid-related deaths occurring in Maryland and amongst Maryland Medicaid beneficiaries.

Prior Authorization (Effective July 1, 2017)

Prior authorization will be required for:

  • 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
OxyContin 30 mg bid
Methadone 20 mg qd
Hydrocodone 10/325, 3 tabs tid

Additionally, some immediate release medications will require prior authorization at less than 90 MME. These medications are as follows:

Medication

Max per 30 days

Unit

Codeine compounds 1,000 mL
180 tablet/capsule
Hydrocodeine compounds 2,750 mL
180 tablet/capsule
Hydromorphone 675 mL
180 tablet/suppository
Meperidine 2,700 mL
180 tablet
Morphine 1,350 mL
180 suppository
Oxycodone compounds 1,800 mL
180 tablet/capsule
Tramadol 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). For more information about the PDMP, visit the MDH web site.
    If you are not already a registered CRISP user you can register for free on the CRISP registration web site.
  • 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.

View the prior authorization form.

View the MDH FAQ on Opioid Prescribing Policies.

Information current as of: 12/14/17