Updated Prior Approval Criteria for Opioid Analgesics

Effective today, June 1, 2018, the clinical coverage criteria for opioid analgesics will be updated. The new changes are:

• Prior approval required for total daily doses greater than 90 morphine milliequivalents (MMEs) per day
• Schedule III and IV opioid analgesics added to the clinical coverage criteria

Prior approval will continue to be required for short-acting opioids for greater than a five-day supply for acute pain and seven-day supply for post-operative acute pain. Prior approval will also continue to be required for long-acting opioids for greater than a seven-day supply.

The prescribing provider may submit prior approval requests to NCTracks through the NCTracks portal or by fax (855-710-1969.) New opioid analgesic prior approval forms and revised clinical coverage criteria will be available on the Pharmacy Services page.

Beneficiaries with diagnosis of pain secondary to cancer will continue to be exempt from prior approval requirements.

*This commnication is taken from the May 2018 Medicaid Pharmacy Newsletter.