Opioid Prior Authorization Requirements

IMPORTANT INFORMATION ABOUT PRESCRIBING OPIOIDS FOR MEDSTAR FAMILY CHOICE-DC HEALTHY FAMILIES AND ALLIANCE ENROLLEES

EARLY REFILL REQUESTS
“Early” Opioid Refills Are Not Covered by MedStar Family Choice
MedStar Family Choice-District of Columbia (MFC-DC) will not authorize early refills of controlled medications. Specifically, MFC-DC 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 enrollee is receiving controlled medication(s) for cancer treatment, sickle cell disease, or is in hospice/receiving palliative care.

PRIOR AUTHORIZATION
Prior Authorization is required for:

  • Prescriptions > 50 MME/day or more than 7 day 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 policy is 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 MFC-DC at 855-798-4244, for Prior Authorization of new opioid prescriptions that exceed the limits.

MFC-DC 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
Medstar Family Choice requires 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. MedStar Family Choice made this decision 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/suppository

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:

  • The prescriber has discussed and will continuously evaluate the risks versus benefits of opioid therapy with the patient.
  • The prescriber will perform random urine drug screening during the course of opioid therapy for this patient.
  • Naloxone has been offered and/or prescribed for the patient.
  • The prescriber and patient have signed an Opioid Treatment Agreement and it is part of the patient’s medical record.
  • Prior to writing each opioid prescription, the prescriber will check the District of Columbia Prescription Drug Monitoring website and review the patient’s prescription history.

View the prior authorization form here

Information current as of: 10/20/20