Skip to Content

Table 8: Opioids and Analgesics


A    B    C    D    E    F    G    H    I    J    K    L    M    N    O    P    Q    R    S    T    U    V    W    X    Y    Z


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

Drug
Notes

buprenorphine buccal film Belbuca PA  
buprenorphine transdermal Butrans PA   - > 20 mcg/hr and PA > 4 patches/28 days BP
fentanyl 12, 25, 50 mcg/hr transdermal system PA   - > 50 mcg/hr and PA > 10 patches/30 days
fentanyl 37.5, 62.5, 87.5 mcg/hr transdermal system PA  
fentanyl 75, 100 mcg/hr transdermal system PA  
hydrocodone extended-release capsule PA  
hydrocodone extended-release tablet Hysingla ER PA  
hydromorphone extended-release PA  
levorphanol tablet PA  
methadone injection PA  
methadone oral-Dolophine Dolophine PA  
methadone oral-Methadose Methadose PA  
morphine controlled-release tablet MS Contin PA   - > 120 mg/day #
morphine extended-release capsule PA  
oxycodone extended-release capsule Xtampza PA  
oxycodone extended-release tablet Oxycontin PA   BP
oxymorphone extended-release, oral PA  
tapentadol extended-release Nucynta ER PA  
tramadol extended-release capsule Conzip PA  
tramadol extended-release tablet 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 ≥ 56 days of Brixadi or 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.

Please note: Opioids and Analgesics that require PA are listed within this therapeutic class table. Managed Care Organizations (MCOs) may have different high dose thresholds and quantity limits. 

 

Acetaminophen Hepatotoxicity:

  • Acetaminophen has been associated with severe hepatotoxicity following acute and chronic ingestion.
  • Maximum recommended dose of acetaminophen for adults is four 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 four grams/day.

Aspirin Dose Limit:

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

Concomitant Opioid and Benzodiazepine Initiative (COBI)

PA is required for members who are newly starting opioid therapy and are stable on benzodiazepine therapy for ≥ 15 days supply within the past 45 days. Members can receive up to a combined total of 14 days supply of one or more opioid(s) within the past 45-day period without PA within dose limits.

High-Dose Opioid and Analgesic Dose Limit:

  • PA is required for certain high-dose opioids and analgesics if used at doses exceeding the established limits. The accumulated high dose threshold is 120 mg of morphine or morphine milligram equivalent (MME) per day for an individual agent, and 180 MME per day for the entire regimen. All buprenorphine formulations are excluded from the opioid accumulator.
  • Please refer to the High-Dose section of this table for individual agents and their respective high-dose thresholds. 

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 members 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 available 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

 

Opioid First-Fill Seven-Day Supply Restriction:

  • In general, members who have not filled an opioid prescription recently (defined as no history of a paid MassHealth pharmacy claim for an opioid in the past 90 days)  or who are naïve to opioids will be limited to a seven-day supply for their first fill.
  • In general, seven-day supply opioid restrictions do not apply to members who already take opioids.
  • Certain exemptions may apply to seven-day supply opioid restrictions.

Please note: In general, members that are residents of nursing homes or chronic care facilities, enrolled in hospice, or with a current diagnosis of cancer or sickle cell disease may be considered on a case-by-case basis for an exemption from select opioid-related requirements (e.g., COBI, high dose criteria documentation, opioid first-fill seven-day supply restriction).

 

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

Drug
Notes

acetaminophen PA   - > 4 g/day *, A90
clonidine injection Duraclon test   #
pentazocine / naloxone PA  

 Opioids and Analgesics – Short-Acting Opioids

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

acetaminophen / codeine PA   - < 12 years and PA > 4 g/day acetaminophen and PA > 360 mg/day codeine
benzhydrocodone / acetaminophen Apadaz PA  
buprenorphine injection Buprenex PA  
butorphanol nasal spray PA  
celecoxib / tramadol Seglentis PA  
codeine PA   - < 12 years and PA > 360 mg/day
dihydrocodeine / acetaminophen / caffeine PA  
fentanyl buccal tablet Fentora PA  
fentanyl injection test  
fentanyl transmucosal system Actiq PA  
hydrocodone / acetaminophen PA   - > 80 mg/day hydrocodone and PA > 4 g/day acetaminophen
hydrocodone / acetaminophen 300 mg PA  
hydrocodone 5 mg, 10 mg / ibuprofen PA  
hydrocodone 7.5 mg / ibuprofen PA   - > 80 mg/day hydrocodone and PA > 3.2 g/day ibuprofen
hydromorphone Dilaudid PA   - > 24 mg/day #
meperidine Demerol PA  
morphine immediate-release PA   - > 120 mg/day
morphine infusion Infumorph test  
morphine suppositories test  
morphine, injection-Astramorph-PF Astramorph-PF PA   - > 120 mg/day
morphine, injection-Duramorph Duramorph PA   - > 120 mg/day
oliceridine Olinvyk PA   MB
oxycodone / acetaminophen PA   - > 80 mg/day oxycodone and PA > 4 g/day acetaminophen
oxycodone / acetaminophen 300 mg PA  
oxycodone / acetaminophen-Percocet Percocet PA   - > 80 mg/day oxycodone and PA > 4 g/day acetaminophen #
oxycodone / aspirin PA   - > 80 mg/day oxycodone and PA > 4 g/day aspirin
oxycodone immediate-release Roxicodone PA   - > 80 mg/day #
oxymorphone immediate-release, oral PA  
sufentanil injection test  
tapentadol Nucynta PA  
tramadol / acetaminophen Ultracet PA  
tramadol 100 mg PA  
tramadol 50 mg Ultram PA   - < 12 years and PA > 400 mg/day #
tramadol solution Qdolo PA  
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. PA 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 PA.
 
MB This drug is available through the health care professional who administers the drug or in an outpatient or inpatient hospital setting. MassHealth does not pay for this drug to be dispensed through the retail pharmacy. If listed, PA does not apply through the hospital outpatient and inpatient settings. Please refer to 130 CMR 433.408 for PA requirements for other health care professionals. Notwithstanding the above, this drug may be an exception to the unified pharmacy policy; please refer to respective MassHealth Accountable Care Partnership Plans (ACPPs) and Managed Care Organizations (MCOs) for PA status and criteria, if applicable.
 
A90 Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply.
 

II. Therapeutic Uses

FDA-approved, for example:

  • acute pain
  • chronic pain

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

Back to top


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.
  • Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply.
  • 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). Other factors, including rebate and FDA-approval status, may change independently of scheduled MassHealth updates, which may result in additional restrictions.
  • 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 ≥ 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.

 

Belbuca

  • Documentation of the following is required: 
    • appropriate diagnosis; and
    • one of the following:
      • adverse reaction or contraindication to morphine sulfate extended-release 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
    • requested dose is ≤ 1,800 mcg/day.

 

benzhydrocodone/acetaminophen, dihydrocodeine/acetaminophen/caffeinehydrocodone/acetaminophen 300mg, hydrocodone 5 mg, 10 mg/ibuprofen, oxycodone/acetaminophen 300 mg

Please refer to table in Section I. Prior-Authorization Requirements: Clinical Notes above for hydrocodone/acetaminophen and oxycodone/acetaminophen strengths available without 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.

  

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 both of the following: buprenorphine transdermal, fentanyl transdermal

 

butorphanol nasal spray

  • Documentation of the following is required for the diagnosis of acute pain:
    • appropriate diagnosis; and
    • requested quantity is ≤ two canisters/30 days; 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 
      • both of the following:
        • medical necessity for nasal spray formulation; and 
        • adverse reaction or contraindication to both of the following: morphine immediate-release solution, oxycodone immediate-release solution.  
  • Documentation of the following is required for the treatment of acute migraine:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction to two or contraindication to all triptans; and
    • one of the following:
      • medical records documenting an inadequate response, adverse reaction to one additional triptan; or
      • medical records documenting an inadequate response, adverse reaction, or contraindication to one agent from a different anti-migraine medication class.
  • Documentation of the following is required for requests noting the member is tapering off butorphanol nasal spray: 
    • indication for the treatment of acute migraine; and
    • medical records documenting the member is on chronic butiorphanol; and
    • treatment plan including taper period for discontinuation.

 

codeine products for members < 12 years of age

  • 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. 

 

fentanyl buccal tablet 

  • 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.

 

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.

    

hydrocodone extended-release capsule, hydrocodone extended-release tablet, hydromorphone extended-release, Nucynta ER (tapentadol extended-release), oxymorphone extended-release, Xtampza (oxycodone 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).  

 

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 instead of 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
    • medical necessity for use instead of oral formulations of methadone. 

 

methadone tablet

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is not opioid naïve; and
    • baseline ECG showing normal QTc interval; and
    • one of the following:
      • adverse reaction or contraindication to both of the following: morphine sulfate extended-release, fentanyl transdermal; or
      • clinical rationale for the use of methadone instead of other long-acting opioids. 

 

morphine extended-release capsules

  • Documentation of the following is required: 
    • appropriate diagnosis; and 
    • inadequate response, adverse reaction, or contraindication to morphine extended-release tablets; and
    • medical necessity for once daily dosing.

 

Nucynta (tapentadol), 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.

  

Olinvyk (oliceridine) 

  • Documentation of the following is required: 
    • diagnosis of acute moderate to severe pain; and
    • inadequate response, adverse reaction, or contraindication to all of the following:
      • fentanyl injection; and  
      • hydromorphone injection; and  
      • morphine injection; and
    • appropriate dosing; and
    • total course of therapy is limited to 48 hours.

     

oxycodone extended-release tablet

  • Documentation of the following is required:   
    • appropriate diagnosis; and
    • adverse reaction or contraindication to one of the following: fentanyl transdermal, morphine sulfate extended-release.

 

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
    • requested dose is ≤ 600 mg/day of pentazocine.

 

Seglentis

  • Documentation of the following is required:
    • diagnosis of management of acute pain; and
    • medical necessity for use of the combination product instead of the commercially available separate agents. 

 

tramadol 100 mg

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the use of the 100 mg tablets instead of the 50 mg tablets; and
    • medical records documenting an inadequate response or adverse reaction to tramadol 50 mg tablet (two 50 mg tablets). 

 

tramadol/acetaminophen

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical necessity for use of the combination product instead of 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 tramadol immediate-release; and 
    • medical necessity for use of an extended-release formulation. 

 

tramadol solution

  • Documentation of the following is required:
    • diagnosis of moderate to severe pain; and
    • member is ≥ 18 years of age; and
    • one of the following:
      • medical necessity for the oral solution formulation; or 
      • medical records documenting inadequate response or adverse reaction to tramadol immediate-release tablets that are available without prior authorization.

 

tramadol products for members < 12 years of age

  • 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 concomitant opioid and benzodiazepine polypharmacy, duplicate therapy, concurrent therapy with opioid dependence agents, high-dose, high-dose short-acting monotherapy, and quantity limit restrictions.

 

Concomitant Opioid and Benzodiazepine Polypharmacy (pharmacy claims for ≥ 15 days supply for one or more opioid(s) [new to therapy] and one or more benzodiazepine(s) [clobazam, nasal and rectal diazepam, nasal midazolam, and injectable formulations are not included] for ≥ 15 days supply within the past 45-day period.

  • If PA is required for concomitant opioid and benzodiazepine polypharmacy, documentation of the following is required
    • individual drug PA criteria must be met first where applicable; and
    • appropriate diagnosis for the opioid; and
    • appropriate diagnosis for the benzodiazepine; and
    • one of the following:
      • member is currently stable on chronic opioid; or 
      • member's treatment is currently managed by palliative care; or
      • member is currently in hospice or is transitioning to hospice; or
      • member is currently being treated for sickle cell disease or cancer pain; or
      • inadequate response or adverse reaction to three non-opioid therapies (e.g., prescription NSAIDs, topical analgesics, physical therapy); or
      • clinical rationale for the use of opioids instead of non-opioid alternatives; or
      • treatment plan to taper off opioid therapy; or
      • treatment plan to taper off or taper down from benzodiazepine therapy; or 
      • clinical rationale for the concomitant use of opioids and benzodiazepines; and
    • member will be co-prescribed naloxone.

 

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

Belbuca (buprenorphine buccal film)

acetaminophen/codeine

Butrans (buprenorphine transdermal)

Actiq, Fentora

Conzip (tramadol extended-release capsule)

Apadaz (benzhydrocodone/acetaminophen)

Dolophine, Methadose (methadone)

Buprenex (buprenorphine injection)

fentanyl transdermal system

butalbital/aspirin/caffeine/codeine

hydrocodone extended-release capsule

butorphanol nasal spray

hydromorphone extended-release

carisoprodol/aspirin/codeine

Hysingla ER (hydrocodone extended-release tablet)

codeine

levorphanol tablet

Demerol (meperidine)

morphine extended-release capsule

dihydrocodeine/acetaminophen/caffeine

MS Contin (morphine controlled-release)

Dilaudid (hydromorphone)

Nucynta ER (tapentadol extended-release)

hydrocodone/acetaminophen

Oxycontin (oxycodone extended-release tablet)

hydrocodone/ibuprofen

oxymorphone extended-release

MSIR (morphine immediate-release)

tramadol extended-release tablet

Nucynta (tapentadol)

Xtampza (oxycodone extended-release capsule)

oxymorphone immediate-release


oxycodone/aspirin

 

Percocet (oxycodone/acetaminophen)

 

pentazocine/naloxone

 

Seglentis (celecoxib/tramadol)

 

tramadol solution

 

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 following limits.

The accumulated high dose threshold is 120 mg of morphine or morphine equivalent (MME) per day for an individual agent, and 180 MME per day for the entire regimen. All buprenorphine formulations are excluded from the opioid accumulator.

 

Long-acting

Short-acting

Belbuca (buprenorphine buccal film)

> 1,800 mcg/day

acetaminophen products

> 4 grams/day

Butrans (buprenorphine transdermal system) > 20 mcg/hr

acetaminophen with codeine products

> 4 grams acetaminophen/day

> 360 mg codeine/day

Conzip (tramadol extended-release capsule) > 300 mg/day

Apadaz (benzhydrocodone/acetaminophen)

> 65.28 mg benzhydrocodone/day

> 4 grams acetaminophen/day

Dolophine, Methadose (methadone) > 25 mg/day

codeine products    

> 360 mg/day

fentanyl transdermal system > 50 mcg/hr

Dilaudid (hydromorphone)

> 24 mg/day

hydrocodone extended-release capsule

 

> 80 mg/day

hydrocodone/acetaminophen

> 80 mg hydrocodone/day

> 4 grams acetaminophen/day

hydromorphone extended-release

> 24 mg/day

hydrocodone/ibuprofen

> 80 mg hydrocodone/day

> 3.2 grams ibuprofen/day

Hysingla ER (hydrocodone extended-release tablet)

> 80 mg/day

morphine immediate-release

> 120 mg/day

levorphanol tablet
> 4 mg/day

oxycodone/acetaminophen

> 80 mg oxycodone/day

> 4 grams acetaminophen/day

morphine extended-release capsule
> 120 mg/day

oxycodone/aspirin

> 80 mg oxycodone/day

> 4 grams aspirin/day

 

MS Contin (morphine controlled-release)
> 120 mg/day

oxymorphone immediate-release

> 40 mg/day

Oxycontin (oxycodone extended-release tablet)
> 80 mg/day

Seglentis (celecoxib/tramadol)

> 400 mg tramadol/day

oxymorphone extended-release
> 40 mg/day

tramadol solution

> 400 mg/day

tramadol extended-release tablet
> 300 mg/day
Ultracet (tramadol/acetaminophen)

> 400 mg tramadol/day

> 4 grams acetaminophen/day

 

Xtampza (oxycodone extended-release capsule) > 72 mg/day

Ultram (tramadol)

> 400 mg/day

 

  • If exceeding four 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 four 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
    • one of the following:
      • diagnosis of sickle cell disease; or
      • diagnosis of active cancer pain; or
      • member’s pain control is currently managed by palliative care; or
      • member is currently in hospice or is transitioning to hospice; or
      • one of the following:
        • all of the following:
          • 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 (Please note, up to three one-month provisional approvals may be allowed to accommodate pain consult scheduling and completion. If requesting a provisional approval to obtain a pain consult, include the specialist contact information and anticipated date of consult); and
          • signed and dated patient-prescriber agreement for opioid use; or
        • both of the following:
          • medical records documenting treatment plan to initiate a taper of the requested medication within the next 90 days; 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

Apadaz (benzhydrocodone/acetaminophen) 

> 65.28 mg benzhydrocodone/day

> 4 grams acetaminophen/day

codeine products    

> 360 mg/day

Dilaudid (hydromorphone)

> 24 mg/day

hydrocodone/acetaminophen

> 80 mg hydrocodone/day

> 4 grams acetaminophen/day

hydrocodone/ibuprofen

> 80 mg hydrocodone/day 

> 3.2 grams ibuprofen/day 

morphine immediate-release  

> 120 mg/day

oxycodone immediate-release

> 80 mg/day

oxycodone/acetaminophen

> 80 mg oxycodone/day

> 4 grams acetaminophen/day

oxycodone/aspirin

> 80 mg oxycodone/day

> 4 grams aspirin/day

oxymorphone immediate-release

> 40 mg/day

Seglentis (celecoxib/tramadol)

> 400 mg tramadol/day

tramadol solution

> 400 mg/day

Ultracet (tramadol/acetaminophen)

> 400 mg tramadol/day

> 4 grams acetaminophen/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 (Please note, up to three one-month provisional approvals may be allowed to accommodate pain consult scheduling and completion. If requesting a provisional approval to obtain a pain consult, include the specialist contact information and anticipated date of consult); 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

Butrans (buprenorphine transdermal system)

> 4 patches/28 days

Conzip (tramadol extended-release capsule) > 1 unit/day
fentanyl transdermal system > 10 patches/30 days
fentanyl 37.5, 62.5, 87.5 mcg/hr transdermal system > 10 patches/30 days

hydrocodone extended-release capsule

> 2 units/day
hydromorphone extended-release
> 1 unit/day
Hysingla ER (hydrocodone extended-release tablet)
> 1 unit/day
levorphanol tablet
> 2 units/day
morphine extended-release capsule
> 1 unit/day
Oxycontin (oxycodone extended-release tablet)
> 3 units/day
oxymorphone extended-release
> 2 units/day
tramadol extended-release tablet
> 1 unit/day
Xtampza (oxycodone extended-release capsule)
> 2 units/day
  • 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: 03/2024


Clinical Criteria Main Page | Back to topPrevious  |  Next

Last updated 05/16/24

Feedback