Provider Quick Alert

November 14, 2017
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:
  1. 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.
  2. 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:
  1. Diagnosis of cancer OR
  2. Patient is receiving end-of-life care OR
  3. All of the following:
    1. 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
    2. A signed informed consent document and an addiction risk assessment AND
    3. 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.
1711 CR 012