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New Opioid Limits and Clinical Prior Authorization Policy for Medicaid Members Effective October 1, 2017

Date: 10/01/17

As previously communicated, effective October 1, 2017 new opioid limits were implemented for all outpatient Medicaid members. These prescribing limits and prior authorization clinical policy were developed at the direction of ODM, and in conjunction with ODM and all five Medicaid Managed Care Plans. Please note the following short-acting opioid dispensing limits:

  • Maximum 7 day supply on prescriptions for new patients
  • Maximum cumulative 14 day supply in a 45 day period for new patients
  • New patients are defined as having less than a 90 day supply of opioids in the previous 120 day time period
  • Maximum average of 60 Morphine Equivalent Dose (MED) per day
  • Prior authorization will be required to prescribe any short-acting opioid outside of these limitations

The above changes apply to short-acting opioids only; all long-acting opioids for new patients will require prior authorization. Please note the following criteria for the prior authorization clinical policy for short-acting opioids:

  • Diagnosis of moderate or severe pain (Prescriber must provide documentation specifying the associated diagnosis/rationale for use).
  • Member has failed at least TWO (2) non-opioid ancillary treatments (such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, anticonvulsants, antidepressants, etc.) at maximum tolerated doses, unless contraindicated.
  • If request is for a non-Preferred Drug List (PDL) drug, member must have failed a trial of TWO (2)* PDL short-acting opioid analgesic for at least > ONE week trial of each, unless contraindicated or clinically significant adverse effects are experienced.
  • Member will be maintained on no more than TWO (2) opioid analgesics concurrently; If member requires therapy with two opioid analgesics concurrently, regimen must consist of one immediate-release and one extended-release analgesic unless contraindicated.
  • Documentation that the provider has reviewed the prescription drug monitoring program (in Ohio – Ohio Automated Rx Reporting System, or OARRS) to identify concurrently prescribed controlled substances.

Please note the following criteria for the prior authorization clinical policy for long-acting opioids:

  • Diagnosis of moderate or severe pain (Prescriber must provide documentation specifying the associated diagnosis/rationale for use).
  • Member must have failed at least > 60 day trial on a short-acting opioid analgesic.
  • If request is for a non-Preferred Drug List (PDL) drug, member must have failed a trial of TWO (2)* PDL short-acting opioid analgesic for at least > ONE week trial of each, unless contraindicated or clinically significant adverse effects are experienced.
  • Member will be maintained on no more than TWO (2) opioid analgesics concurrently; *If member requires therapy with two opioid analgesics concurrently, regimen must consist of one immediate-release and one extended-release analgesic unless contraindicated.
  • For initial therapy, cumulative opioid dose does NOT exceed 80 MED per day.
  • Documentation that the provider has reviewed the prescription drug monitoring program (in Ohio – Ohio Automated Rx Reporting System, or OARRS) to identify concurrently prescribed controlled substances.

*Provided TWO (2) agents exist in the therapeutic category with comparable labeled indications.

If you have any questions regarding the rule related to the review of OARRS, please click on this link for more information: http://codes.ohio.gov/oac/4731-11-11v1. For questions regarding access to OARRS or how to use it, please call 614-466-4143. Members with the following conditions will be exempted from the prior authorization criteria for short-acting and long-acting opioids (providers must submit documentation of these conditions in the prior authorization request):

  • Active cancer treatment
  • Palliative care
  • Hospice/end-of-life care
  • Sickle cell crisis
  • Severe burns
  • Traumatic crushing of tissue
  • Amputation
  • Major orthopedic surgery

Please contact Buckeye’s Provider Services Department at 1-866-296-8731 with any questions. Thank you for your partnership and for the quality care you provider to Buckeye members.