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Drug Category: Pain and Inflammation

Medication Class/Individual Agents: Opioids and Analgesics

I. Prior-Authorization Requirements

 Opioids and Analgesics – Long-Acting Opioids

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

buprenorphine buccal film Belbuca PA  
buprenorphine transdermal Butrans BP PA   - > 20 mcg/hr and PA > 4 patches/28 days
fentanyl 12, 25, 50 mcg/hr transdermal system Duragesic # PA   - > 50 mcg/hr and PA > 10 patches/month
fentanyl 37.5, 62.5, 87.5 mcg/hr transdermal system PA  
fentanyl 75, 100 mcg/hr transdermal system Duragesic PA  
hydrocodone extended-release capsule Zohydro ER PA  
hydrocodone extended-release tablet Hysingla ER PA  
hydromorphone extended-release Exalgo PA  
levorphanol powder PA  
levorphanol tablet PA  
methadone injection PA  
methadone oral-Dolophine Dolophine PA  
methadone oral-Methadose Methadose PA  
methadone powder PA  
morphine / naltrexone Embeda PA  
morphine controlled-release tablet MS Contin # PA   - > 120 mg/day
morphine extended-release capsule Kadian PA  
morphine extended-release capsule PA  
morphine extended-release tablet-Arymo ER Arymo ER PA  
morphine extended-release tablet-Morphabond ER Morphabond ER PA  
oxycodone extended-release capsule Xtampza PA  
oxycodone extended-release tablet Oxycontin BP PA  
oxymorphone extended-release, oral PA  
tapentadol extended-release Nucynta ER PA  
tramadol extended-release capsule Conzip PA  
tramadol extended-release tablet Ultram ER PA  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

Please note: PA will be required if it is determined that the member is stable on opioid dependence therapy (≥ 60 days of therapy within the last 90 days of an oral opioid dependence agent, or Probuphine in the past 210 days, or ≥ 56 days of Sublocade in the last 84 days) for any long-acting opioid agent, any short-acting opioid agent > 7 days supply, and any short-acting opioid agent if there is ≥ 7 days of a short-acting opioid agent in the last 30 days.

  

Acetaminophen Hepatotoxicity:

  • Acetaminophen has been associated with severe hepatotoxicity following acute and chronic ingestion.
  • Maximum recommended dose of acetaminophen for adults is 4 grams/day.
  • Be sure to consider and ask about all potential sources of acetaminophen (e.g., OTC, combination analgesics) when determining daily acetaminophen dose.
  • Risk may increase with concurrent alcohol use, underlying liver disease, and/or the fasting state.
  • PA is required for any acetaminophen-containing product that exceeds 4 grams/day.

Aspirin Dose Limit:

  • The maximum recommended dose of aspirin for adults is 4 grams/day.
  • PA is required for any aspirin-containing product that exceeds 4 grams/day.

Ibuprofen Dose Limit:

  • The maximum recommended dose of ibuprofen for adults is 3.2 grams/day.
  • PA is required for any ibuprofen-containing product that exceeds 3.2 grams/day.

Duplicate Opioid Therapy:

  • Standard practice in chronic pain management includes a long-acting opioid for chronic pain and a short-acting opioid for acute/breakthrough pain as needed.
  • PA is required for ≥ two long-acting opioids for > two months.
  • PA is required for ≥ two short-acting opioids for > two months.

Allergy:

  • True systemic opioid allergy, such as a generalized rash, or angioedema, is unusual. A local, itchy wheal formation at the site of narcotic injection, generalized pruritus (no rash), or flushing may occur, and is due to histamine release. 

Renal Dysfunction:

  • Accumulation of certain opioids in patients with significant renal dysfunction can lead to excess sedation, respiratory depression, delirium, myoclonus, or seizures.
    • avoid use: meperidine, tapentadol (severe impairment), tramadol (severe impairment)
    • cautious use: acetaminophen, codeine, hydrocodone, morphine, oxycodone

Constipation:

  • Common adverse effect with chronic opioid use; prescribe laxative +/- stool softener with opioid.

Hydrocodone and oxycodone in combination with acetaminophen:

  • Generically available solution formulations continue to be available without PA within dose limits.
  • Select generic tablet formulations continue to be covered without PA within dose limits. These include the following products.

 

Hydrocodone or Oxycodone Strength

Acetaminophen Strength

2.5 mg

325 mg

5 mg

325 mg

7.5 mg

325 mg

10 mg

325 mg

 

Please click on the link below to see the Opioid and Pain Initiative.

MassHealth Pharmacy Initiatives and Clinical Information

 

For additional information about Opioids (e.g., Letters to Prescribers), go to the following link.
https://www.mass.gov/lists/opioids-and-controlled-substances-information

 

 

 

 Opioids and Analgesics – Other Analgesics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

acetaminophen * PA   - > 4 g/day
clonidine injection Duraclon # test  
pentazocine Talwin test  
pentazocine / naloxone PA  
ziconotide Prialt PA  

 Opioids and Analgesics – Short-Acting Opioids

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

acetaminophen / codeine Tylenol / Codeine # PA   - < 12 years and PA > 4 g/day acetaminophen and PA > 360 mg/day codeine
buprenorphine injection Buprenex PA  
butorphanol nasal spray PA  
codeine PA   - < 12 years and PA > 360 mg/day
codeine powder PA  
dihydrocodeine / acetaminophen / caffeine PA  
dihydrocodeine / aspirin / caffeine Synalgos-DC PA  
fentanyl buccal tablet Fentora PA  
fentanyl injection test  
fentanyl nasal spray Lazanda PA  
fentanyl powder PA  
fentanyl sublingual spray Subsys PA  
fentanyl sublingual tablet Abstral PA  
fentanyl transmucosal system Actiq PA  
hydrocodone / acetaminophen PA   - > 80 mg/day
hydrocodone / acetaminophen 300 mg PA  
hydrocodone 5 mg, 10 mg / ibuprofen PA  
hydrocodone 7.5 mg / ibuprofen PA   - > 80 mg/day
hydrocodone powder PA  
hydromorphone Dilaudid # PA   - > 32 mg/day
hydromorphone powder PA  
meperidine Demerol PA  
morphine immediate-release PA   - > 120 mg/day
morphine infusion Infumorph test  
morphine powder PA  
morphine suppositories test  
morphine, injection-Astramorph-PF Astramorph-PF PA   - > 120 mg/day
morphine, injection-Duramorph Duramorph PA   - > 120 mg/day
oxycodone / acetaminophen PA   - > 80 mg/day
oxycodone / acetaminophen 300 mg PA  
oxycodone / acetaminophen extended-release Xartemis XR PA  
oxycodone / acetaminophen-Percocet Percocet # PA   - > 80 mg/day
oxycodone / aspirin PA   - > 4 g/day aspirin
oxycodone / ibuprofen PA  
oxycodone immediate-release-Roxicodone Roxicodone # PA   - > 80 mg/day
oxycodone powder PA  
oxycodone-immediate-release-Oxaydo Oxaydo PA  
oxymorphone immediate-release, oral Opana IR PA  
sufentanil injection Sufenta test  
sufentanil powder PA  
tapentadol Nucynta PA  
tramadol Ultram # PA   - < 12 years and PA > 400 mg/day
tramadol / acetaminophen Ultracet PA  
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.
 

II. Therapeutic Uses

FDA-approved, for example:

  • acute pain
  • chronic pain

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, frequency, and formulation.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon the member's condition, requested medication, and Duplicate Therapy, High Dose, High Dose Short-Acting Monotherapy, and Quantity Limit restrictions (see below).
  • If MassHealth pharmacy claims history of required trials is not available, medical records documenting such trials may be required.

 

Please note: PA will be required if it is determined that the member is stable on opioid dependence therapy (≥ 60 days of therapy within the last 90 days of an oral opioid dependence agent, or Probuphine in the past 210 days, or ≥ 56 days of Sublocade in the last 84 days) for any long-acting opioid agent, any short-acting opioid agent > seven days supply, and any short-acting opioid agent if there is ≥ seven days of a short-acting opioid agent in the last 30 days.

 

Abstral (fentanyl sublingual tablet), fentanyl buccal tablet, Lazanda (fentanyl nasal spray), Subsys (fentanyl sublingual spray)

  • Documentation of the following is required:
    • indication of breakthrough cancer pain; and 
    • adverse reaction or contraindication to all of the following:  
      • hydromorphone immediate-release; and  
      • morphine immediate-release; and  
      • oxycodone immediate-release; and  
      • fentanyl transmucosal system (generic Actiq) (requires PA - see criteria below); and  
    • member is maintained on a long-acting opioid regimen; and 
    • prescriber is an oncologist or pain specialist.

 

Arymo ER (morphine extended-release tablet), Embeda (morphine/naltrexone), Exalgo (hydromorphone extended-release), Hysingla ER (hydrocodone extended-release tablet), Morphabond ER (morphine extended-release tablet), Nucynta ER (tapentadol extended-release), oxymorphone extended-release, Xtampza (oxycodone extended-release capsule), Zohydro ER (hydrocodone extended-release capsule)

  • Documentation of the following is required:
    • appropriate diagnosis; and 
    • adverse reaction or contraindication to all of the following that cannot be expected or managed as a part of opioid therapy:    
      • fentanyl transdermal; and 
      • morphine extended-release; and  
      • oxycodone extended-release tablet (requires PA - see criteria below).  

 

Belbuca (buprenorphine buccal film)

  • Documentation of the following is required: 
    • appropriate diagnosis; and
    • one of the following:
      • adverse reaction or contraindication to long-acting morphine sulfate that cannot be expected or managed as a part of opioid therapy; or  
      • medical necessity for buccal formulation; or 
      • prescriber wants to avoid using a full opioid agonist; and
    • dose does not exceed 1,800 mcg/day.

  

Buprenex (buprenorphine injection)

  • Documentation of the following is required: 
    • appropriate diagnosis; and
    • clinical rationale why oral pain medications cannot be used; and
    • adverse reaction or contraindication to fentanyl transdermal that cannot be expected or managed as a part of opioid therapy; and
    • adverse reaction or contraindication to buprenorphine transdermal. 

   

butorphanol nasal spray

  • Documentation of the following is required:
    • diagnosis of acute pain; and
    • quantity is ≤ two canisters/month; and
    • medical records documenting one of the following:
      • adverse reaction or contraindication to all other generic short-acting opioids: codeine, hydromorphone, morphine, and oxycodone; or 
      • medical necessity for nasal spray formulation and adverse reaction or contraindication to both morphine immediate-release solution and oxycodone immediate-release solution.

  

codeine products for members < 12 years old

  • Documentation of one of the following is required:
    • CYP2D6 genotyping confirms member is not an ultra-rapid CYP2D6 metabolizer; or 
    • member has previously utilized a codeine-containing product without adverse effect that prevents repeat use. 

 

dihydrocodeine/acetaminophen/caffeine, dihydrocodeine/aspirin/caffeine, hydrocodone/acetaminophen 300mg, hydrocodone 5 mg, 10 mg/ibuprofen, oxycodone/acetaminophen 300 mg, oxycodone/ibuprofen, Xartemis XR (oxycodone/acetaminophen extended-release)

Please refer to table in Section I. Prior-Authorization Requirements: Clinical Notes above for hydrocodone/acetaminophen and oxycodone/acetaminophen strengths that do not require PA within dose limits.

  • For strengths and formulations that require PA, documentation of the following is required:  
    • appropriate diagnosis; and 
    • medical records documenting an inadequate response, adverse reaction, or contraindication to all of the following:  
      • codeine/acetaminophen; and  
      • hydrocodone/acetaminophen; and 
      • hydrocodone/ibuprofen; and
      • oxycodone/acetaminophen.

 

fentanyl 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr transdermal system

  • Documentation of the following is required:
    • clinical rationale why two patches cannot be combined to obtain the equivalent strength requested.  

 

fentanyl transmucosal system (Actiq)

  • Documentation of the following is required:
    • indication of breakthrough cancer pain; and 
    • adverse reaction or contraindication to all of the following:   
      • hydromorphone immediate-release; and  
      • morphine immediate-release; and  
      • oxycodone immediate-release; and
    • member is maintained on a long-acting opioid regimen; and
    • prescriber is an oncologist or pain specialist.

    

levorphanol tablet

  • Documentation of the following is required: 
    • adverse reaction or contraindication to all of the following that cannot be expected or managed as a part of opioid therapy:    
      • fentanyl transdermal; and 
      • morphine extended-release; and  
      • oxycodone extended-release tablet (requires PA - see criteria below); and
    • clinical rationale for use of the requested agent over all other long-acting opioids.  

  

meperidine

  • Documentation of the following is required: 
    • appropriate diagnosis; and 
    • allergy to morphine; and 
    • member has not used morphine derivatives since documented date of morphine allergy. 

    

methadone injection

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • clinical rationale for use over oral formulations of methadone. 

 

methadone tablet

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is not opioid naive; and
    • baseline ECG showing normal QTc interval; and
    • one of the following:
      • adverse reaction or contraindication to long-acting morphine sulfate and fentanyl transdermal that cannot be expected or managed as a part of opioid therapy; or
      • clinical rationale for the use of oral methadone over other long-acting opioids. 

 

morphine extended-release capsules (Kadian, generics)

  • Documentation of the following is required: 
    • appropriate diagnosis; and 
    • clinical rationale for use in place of long-acting generic morphine tablets.  

 

Nucynta (tapentadol), Opana IR (oxymorphone immediate-release)

  • Documentation of the following is required:   
    • appropriate diagnosis; and
    • adverse reaction or contraindication to all of the following:   
      • hydromorphone immediate-release; and  
      • morphine immediate-release; and  
      • oxycodone immediate-release.

 

opioid powders

  • Documentation of the following is required:   
    • appropriate diagnosis; and 
    • clinical rationale why other commercially available alternatives cannot be used. 

 

Oxaydo (oxycodone immediate-release)

  • Documentation of the following is required:
    • clinical rationale as to why the generically available 5 mg tablets cannot be used.

  

oxycodone extended-release tablet

  • Documentation of the following is required:   
    • appropriate diagnosis; and 
    • adverse reaction or contraindication to long-acting morphine sulfate or fentanyl transdermal that cannot be expected or managed as a part of opioid therapy. 

 

pentazocine/naloxone

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • adverse reaction or contraindication to all of the following:   
      • one nonsteroidal anti-inflammatory drug (NSAID); and
      • hydromorphone immediate-release; and
      • morphine immediate-release; and
      • oxycodone immediate-release; and
      • tramadol; and
    • dose does not exceed 600 mg/day of pentazocine.

 

Prialt (ziconotide intrathecal injection)

  • Documentation of the following is required:  
    • appropriate diagnosis; and 
    • member is intolerant or refractory to other treatments such as systemic analgesics and adjunctive therapy; and
    • member is intolerant or refractory to intrathecal morphine. 

 

tramadol/acetaminophen

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • clinical rationale for use of the combination product over the commercially available separate agents. 

 

tramadol extended-release capsule, tablet

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction to generic tramadol immediate-release; and 
    • clinical rationale for use of an extended-release formulation. 

 

tramadol products for members < 12 years old

  • Documentation of the following is required:
    • individual drug PA criteria must be met first where applicable; and
    • one of the following:
      • CYP2D6 genotyping confirms member is not an ultra-rapid CYP2D6 metabolizer; or 
      • member has previously utilized a tramadol-containing product without adverse effect that prevents repeat use. 

 

In addition to individual drug PA criteria above, some opioids are subject to additional Duplicate Therapy, Concurrent Therapy with Opioid Dependence Agents, High Dose, High Dose Short-Acting Monotherapy, and Quantity Limit restrictions.

 

Duplicate Therapy and Concurrent Therapy with Opioid Dependence Agents

The following opioids require PA if there is concurrent use of two long-acting or two short-acting opioids for at least 60 days out of any 180-day period. In addition, PA will be required if it is determined that the member is stable on opioid dependence therapy, for any long-acting opioid agent, any short-acting opioid agent > seven days supply, and any short-acting opioid agent if there is ≥ seven days of a short-acting opioid agent in the last 30 days.

 

Long-acting

Short-acting

Arymo ER (morphine extended-release tablet)

Abstral, Actiq, Fentora, Lazanda, Subsys  (fentanyl immediate-release)

Belbuca (buprenorphine buccal film)

Buprenex (buprenorphine injection)

Butrans (buprenorphine transdermal)

butalbital/aspirin/caffeine/codeine

Conzip (tramadol extended-release capsule)

butorphanol nasal spray

Dolophine, Methadose (methadone)

carisoprodol/aspirin/codeine

Duragesic (fentanyl transdermal system)

codeine

Embeda (morphine/naltrexone)

Demerol (meperidine)

Exalgo (hydromorphone extended-release)

dihydrocodeine/acetaminophen/caffeine

Hysingla ER (hydrocodone extended-release tablet)

Dilaudid (hydromorphone)

Kadian (morphine extended-release capsule)

hydrocodone/acetaminophen

levorphanol tablet

hydrocodone/ibuprofen

Morphabond ER (morphine extended-release tablet)

MSIR (morphine immediate-release)

morphine extended-release capsule

Nucynta (tapentadol)

MS Contin (morphine controlled-release)

Opana IR (oxymorphone immediate-release)

Nucynta ER (tapentadol extended-release)

Oxaydo (oxycodone immediate-release)

Oxycontin (oxycodone extended-release tablet)

oxycodone/aspirin

oxymorphone extended-release

oxycodone/ibuprofen

Ultram ER (tramadol extended-release tablet)

Percocet, Xartemis XR (oxycodone/acetaminophen)

Xtampza (oxycodone extended-release capsule)

pentazocine/naloxone

Zohydro ER (hydrocodone extended-release capsule)

Prialt (ziconotide)

 

Synalgos-DC (dihydrocodeine/aspirin/caffeine)

 

Tylenol/Codeine (acetaminophen/codeine)

 

Ultracet (tramadol/acetaminophen)

 

Ultram (tramadol)

  • If PA is required for duplicate therapy, documentation of the following is required: 
    • appropriate diagnosis; and
    • individual drug PA criteria must be met first where applicable; and
    • clinical rationale for not maximizing opioid monotherapy.

 

  • If PA is required for concurrent therapy with opioid dependence agents, documentation of the following is required: 
    • individual drug PA criteria must be met first where applicable; and
    • clinical rationale why concurrent therapy with buprenorphine is clinically appropriate.

   

High-Dose

The following opioids and analgesics require PA for high-dose if used at doses exceeding the limits listed below.

 

Long-acting

Short-acting

Arymo ER (morphine extended-release tablet)

> 120 mg/day

acetaminophen products

> 4 grams/day

Belbuca (buprenorphine buccal film)

> 1,800 mcg/day

acetaminophen with codeine products

> 4 grams acetaminophen/day

> 360 mg codeine/day

Butrans (buprenorphine transdermal system)

> 20 mcg/hr

codeine products    

> 360 mg/day

Conzip (tramadol extended-release capsule)

> 300 mg/day

Dilaudid (hydromorphone)

> 32 mg/day

Dolophine, Methadose (methadone)

> 30 mg/day

hydrocodone/acetaminophen

> 80 mg/day

Duragesic (fentanyl transdermal system)

> 50 mcg/hr

hydrocodone/ibuprofen

> 80 mg hydrocodone/day

> 3.2 grams ibuprofen/day

Embeda (morphine/naltrexone)

> 120/4.8 mg/day

morphine immediate-release

> 120 mg/day

Exalgo (hydromorphone extended-release)

> 32 mg/day

Opana (oxymorphone immediate-release)

> 40 mg/day

Hysingla ER (hydrocodone extended-release tablet)

> 80 mg/day

Oxaydo (oxycodone immediate-release)

> 80 mg/day

Kadian (morphine extended-release capsule)

> 120 mg/day

oxycodone/acetaminophen

> 80 mg/day

levorphanol tablet

> 4 mg/day

oxycodone/aspirin

> 4 grams aspirin/day

Morphabond ER (morphine extended-release tablet)

> 120 mg/day

oxycodone/ibuprofen

> 80 mg oxycodone/day

> 3.2 grams ibuprofen/day

morphine extended-release capsule

> 120 mg/day

Ultracet (tramadol/acetaminophen)

> 4 grams acetaminophen/day

> 400 mg tramadol/day

MS Contin (morphine controlled-release)

> 120 mg/day

Ultram (tramadol)

> 400 mg/day

Oxycontin (oxycodone extended-release tablet)

> 80 mg/day

 

 

oxymorphone extended-release

> 40 mg/day

 

 

Ultram ER (tramadol extended-release tablet)

> 300 mg/day

 

 

Xtampza (oxycodone extended-release capsule)

> 72 mg/day

 

 

Zohydro ER (hydrocodone extended-release capsule)

> 80 mg/day

 

 

  • If exceeding 4 grams/day of an acetaminophen- or aspirin-containing product, or 3.2 grams/day of an ibuprofen-containing product, documentation of the following is required:
    • appropriate diagnosis; and
    • individual drug PA criteria must be met first, where applicable; and
    • clinical rationale for utilizing greater than 4 grams of acetaminophen or aspirin, or greater than 3.2 grams of ibuprofen per day.

 

  • If exceeding the above high-dose limits for other agents, documentation of the following is required: 
    • appropriate diagnosis; and
    • individual drug PA criteria must be met first, where applicable; and
    • medical records documenting treatment plan, including clinical rationale for high-dose and titration of medication up to current dose; and
    • pain consult from a pain specialist or hematologist/oncologist supporting the high dose of opioid requested; and
    • signed and dated patient-prescriber agreement for opioid use.

 

High-Dose, Short-Acting Monotherapy

The following opioids and analgesics require PA for monotherapy if used at doses exceeding the limits listed below.

 

Short-acting

acetaminophen with codeine products    

> 4 grams acetaminophen/day

> 360 mg codeine/day

codeine products    

> 360 mg/day

Dilaudid (hydromorphone)

> 32 mg/day

hydrocodone/acetaminophen

> 80 mg/day

hydrocodone/ibuprofen

> 80 mg/day hydrocodone

> 3.2 grams/day ibuprofen

morphine immediate-release  

> 120 mg/day

Opana (oxymorphone immediate-release)  

> 40 mg/day

Oxaydo (oxycodone immediate-release) 

> 80 mg/day

oxycodone immediate-release

> 80 mg/day

oxycodone/acetaminophen

> 80 mg/day

oxycodone/aspirin

> 4 grams/day aspirin

oxycodone/ibuprofen

> 80 mg/day oxycodone

> 3.2 grams/day ibuprofen

Ultracet (tramadol/acetaminophen)

> 4 grams acetaminophen/day

> 400 mg tramadol/day

Ultram (tramadol)

> 400 mg/day

 

  • If exceeding the above high-dose limits and using as monotherapy, documentation of the following is required: 
    • individual drug PA criteria must be met first, where applicable; and
    • medical records documenting treatment plan, including clinical rationale for high-dose and titration of medication up to current dose; and
    • pain consult from a pain specialist supporting the high dose of opioid requested; and
    • clinical rationale for not utilizing a long-acting agent in a member requiring high-dose, short-acting opioid therapy for the treatment of chronic pain; and
    • signed and dated patient-prescriber agreement for opioid use.

 

Quantity Limits

The following opioids require PA if used at the quantities listed below.

 

Long-acting

Arymo ER (morphine extended-release tablet)

> 90 tablets/month

Butrans (buprenorphine transdermal system)

> 4 patches/28 days

Conzip (tramadol extended-release capsule)

> 30 capsules/month

Duragesic (fentanyl transdermal system)

> 10 patches/month

Embeda (morphine/naltrexone)

> 30 capsules/month

Exalgo (hydromorphone extended-release)

> 30 tablets/month

fentanyl 37.5, 62.5, 87.5 mcg/hr transdermal system

> 10 patches/month

Hysingla ER (hydrocodone extended-release tablet)

> 30 tablets/month

Kadian (morphine extended-release capsule)

> 30 capsules/month

levorphanol tablet

> 60 tablets/month

Morphabond ER (morphine extended-release tablet)

> 60 tablets/month

morphine extended-release capsule

> 30 capsules/month

Oxycontin (oxycodone extended-release tablet)

> 90 tablets/month

oxymorphone extended-release

> 60 tablets/month

Ultram ER (tramadol extended-release tablet)

> 30 tablets/month

Xtampza (oxycodone extended-release capsule)

> 60 capsules/month

Zohydro ER (hydrocodone extended-release capsule)

> 60 capsules/month

  • If exceeding the above quantity limits, documentation of the following is required: 
    • appropriate diagnosis; and
    • individual drug PA criteria must be met first, where applicable; and
    • requested dose cannot be obtained within the established quantity limits.


Original Effective Date: 08/2002

Last Revised Date: 08/2019


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Last updated 11/18/19