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Provider News Authorization Changes in Effect for Opioid Prescriptions

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In March of 2016, the Centers for Disease Control and Prevention (CDC) released the Guideline for Prescribing Opioids for Chronic Pain. The summary of evidence demonstrates that the risk of opioid use greatly outweighs the benefit for most patients. Their in-depth review echoed conclusions drawn by many other organizations – the benefit gained from the long-term use of opioids for chronic, non-cancer pain, does not outweigh the associated risks of using the medication.

Population studies of death rates and prescribing practices demonstrate a close relationship between the number of opioids prescribed and deaths related to their use. In short, there is inadequate evidence to support long-term opioid use for chronic, non-cancer pain.

In an effort to support and promote safe opioid use and appropriate pain management, IHN-CCO, Samaritan Employer Group Plans and Samaritan Choice Plans are implementing new authorization criteria following CDC guidelines.

Authorization Criteria Changes 

Key highlights of the authorization criteria changes are as follows:

  • Short-Acting Opioid (SAO) medication (brand or generic product)
    • New to Therapy: Member Limits on Short Acting Opioids
      • Members who are new to opioid therapy (no opioid in their most recent 120-day claims history), will be limited to a maximum of 49 morphine-equivalent mg per day of an opioid medication per fill, max. 7-day supply, limit 2 fills within 60-day timeframe.
    • Treatment Experienced Member Limits on Short Acting Opioids
      • Members who are NOT new to therapy (have opioid fills in their most recent 120-day claims history), will be limited to a maximum of 90 morphine-equivalent mg per day of an opioid medication per fill, and subject to 2 fills within a 60-day timeframe.
  • Long-Acting Opioid (LAO) medication (brand or generic product)
    • Plan will require a Prior Authorization for all long acting opioids, including new starts, which will require step therapy with a short acting opioid prior to starting a long acting opioid beginning 09/01/18
  • Age-based Prior Authorizations for Antitussive
    • Prior Authorization will be required for all members under 12 years of age
    • Prior Authorization will be required for members between 12-17 years of age that have a medication for asthma, COPD, or obesity in the most recent 365 days
  • Quantity Limits for ALL AGES
    • Liquid formulations of antitussives will be limited to a maximum of 240ml per fill
    • Tablet/capsule formulations will be limited to a maximum of 7-day supply fill
    • Additional quantities over the maximum daily dose will require a Prior Authorization
    • A maximum of 2 fills (liquid or tablet/capsule) within a 60-day period

Please Note: Edits will first screen the past 365 days of a member’s profile for oncology drugs and will not require a prior authorization if one is found.

 

A Prior Authorization May Be Pursued if Clinically Necessary

Additional treatment/increased quantities will be approved with a PA when one of the following criteria are met:

  • Diagnosis of Cancer, or
  • Patient is receiving opioids as part of end of life care, or
  • All of the following:
    • The prescriber certifies that there is an active treatment plan that includes but is not limited to a specific treatment objective and the use of other pharmacological and nonpharmacological agents for pain relief as appropriate, and
    • The prescriber certifies that there has been an informed consent document signed and an addiction risk assessment has been performed, and
    • The prescriber certifies that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists

Benefit Change Effective September 1

A letter has been mailed to members to make them aware of the upcoming changes and provide them with a better understanding of the reasons behind the new prescribing limits. If you have any questions, please call Customer Service at 888-435-2396 or 541-768-5207 or TTY 800-735-2900, Monday through Friday from 8 a.m. to 8 p.m.

Talk with our Provider Services representatives 

call us at 541-768-5207 1-888-435-2396 8 a.m. to 6 p.m.
Mon. - Fri.