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Short-Acting Opioid Limits to be Implemented 12/1/2017
Effective December 1, 2017, QualChoice will implement limits on the number of Morphine Milligram Equivalents (MME) a member can receive at any given time of a Short-Acting Opioid (SAO) medication (brand or generic).
These limits are based on the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain-2016.
Note: We will not limit quantity if an oncology drug is found in the last 360 days of a member's Rx profile.
There will be separate limits on SAOs for:
- Members Who Are New to Therapy
Members who have NO opioid in their last 120 days of Rx claims history will be limited to a maximum of 49 morphine-equivalent mg per day of an opioid medication per fill, maximum 7-day supply, and 2 fills within a 60-day timeframe.
- Members Who Are NOT New to Therapy
Members who DO have opioid fills in their last 120 days of Rx 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.
If clinically necessary, pre-authorization may be pursued for doses above the CDC recommended limits. Criteria will require one of the following:
- Diagnosis of cancer OR
- Patient is receiving end-of-life care OR
- All of the following:
- An active treatment plan including, but not limited to, a specific treatment objective and the use of other pharmacological and non-pharmacological agents for pain relief as appropriate AND
- A signed informed consent document and an addiction risk assessment AND
- A written/signed agreement between prescriber and patient addressing prescription management, diversion, and the use of other substances.
To request pre-authorization, call OptumRx at 1.877.629.3118.
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