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Prior Authorizations for Opioid Prescriptions

The Pennsylvania Department of Human Services (DHS) mandates that all Medicaid managed care organizations (MCOs) in Pennsylvania implement prior authorization requirements for opioid prescriptions. These include prior authorization requirements for Medicaid participants. In accordance with this mandate, effective September 15, 2017, Health Partners Plans (HPP) implemented new policies regarding opioids.

 

The details and the staggered implementation dates for these new policies are shown below. Please be aware that members who are being treated for cancer, sickle cell anemia, and those on hospice care are exempt from these criteria.

EFFECTIVE 9/15/2017

  • A urine drug screen (UDS) will be required for every prior authorization.
    • Concomitant use of opioids and benzodiazepines will only be allowed if a titration plan for the opioid or benzodiazepine is documented.
    • Patients must be evaluated for risk of opioid-related harm. If a patient is deemed high risk, documentation must be included that clearly indicates that a prescription for naloxone will be considered.
    • Prior authorization approval will be allowed for therapies that are titrated downward.
      • Duration of approval will match the duration of titration.
      • Titration schedule must be included in the prior authorization request.
  • When submitting prior authorization requests, providers must confirm that the Pennsylvania Prescription Drug Monitoring Program (PA PDMP) was checked.

PRIOR AUTHORIZATION REQUIREMENTS, MEMBERS UNDER 21 YEARS OF AGE

  • Prior authorization is required for all opioid containing medications (formulary and non-formulary) when the newly prescribed opioid exceeds a seven day supply AND will be limited to one opioid containing prescription of seven days or less per 365 days regardless of whether the member has taken an opioid previously. This applies to all new starts and current members taking an opioid prescription.

PRIOR AUTHORIZATION REQUIREMENTS, MEMBERS 21 YEARS OF AGE AND OLDER

  • Prior authorization is required for all opioid containing medications (formulary and non-formulary) for NEW starts when the newly prescribed opioid exceeds a 14-day supply. 
  • EFFECTIVE 1/1/2018: Prior authorization will be required for all opioid containing medications (formulary and non-formulary) when the opioid prescription exceeds a 14 day supply AND will be limited to one opioid containing prescription of 14 days or less per 365 days for all members regardless of previous opioid utilization.

DOSAGE-BASED AUTHORIZATION REQUIREMENT

Prior authorizations are required for all opioid prescriptions that exceed a specific dose of milligrams of morphine equivalent (MME). Member disruption letters will be sent at least 33 days prior to implementation. This requirement will be applied as shown below:

-    10/16/2017:       240mg MME per day will require prior authorization

-    11/13/2017:       120mg MME per day will require prior authorization

-    1/1/2018:           90mg MME per day will require prior authorization

Click here for the MME conversion chart for more information.

ADDITIONAL INFORMATION

This policy is based on guidelines released by the Centers for Disease Control and Prevention (CDC) in 2016 and the Pennsylvania Guidelines on the Use of Opioids to Treat Chronic Non-Cancer Pain in 2014.

To minimize the potential negative impact to your patients, please assess their opioid prescription therapy and consider lowering the dose and/or switching to non-opioid or non-pharmacologic therapy when appropriate. If you need assistance with your members who are on opioid-containing medications, we can assist with pharmacy profiles to help you manage these members.

Find our searchable formulary and the most up-to-date prior authorization forms on our Tools and Resources page. 

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