Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

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Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.


Effective Date: 01/01/2019 Title: Opioid Therapy for Chronic Pain and Long-Acting Opioids
Revision Date: 02/01/2020 Document: BI583:00
CPT Code(s):
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Long-Acting Opioids (LAOs) require prior authorization. If approved, the initial authorization will be for 2 months. These products result in a more continuous exposure to the effects of opioids and can result in fewer (or less dramatic) “peaks and valleys.” Long-acting opioids may be considered for patients with chronic pain as part of a comprehensive, multimodal treatment plan if preferred pain management interventions have not been effective in achieving functional improvement.

Chronic pain, for the purposes of this policy, is defined as pain lasting > 3 months or past the expected time for normal wound healing. Chronic pain is more likely to be associated with nervous system changes that alter pain perception and pain regulatory mechanisms. In some cases, opioid use may actually contribute to chronic pain rather than help control it, through something called opioid-induced hyperalgesia.

To effectively treat chronic pain, a thorough evaluation is needed to categorize the cause(s) of chronic pain and develop a comprehensive treatment plan tailored to the individual patient. One-size-fits all treatment plans are less likely to produce the desire outcomes and are more likely to be associated with undesirable side effects. First line/preferred treatments may vary depending on the cause/source of the pain, but long-acting opioids are never considered the first line treatment for chronic pain of any type. Please refer to CDC Guideline for Prescribing Opioids for Chronic Pain.

For short acting opioids, please refer to BI566 Opioid Therapy For Chronic Pain And short-Acting Opioids.

Medical Statement

Long-acting opioids result in more continuous nervous system exposure to the effects of opioids, with fewer (or less dramatic) “peaks and valleys.”  This long-acting effect can be achieved through the use of opioids with longer half-lives, through delayed/timed release mechanisms or a combination of both.  Long-acting opioids are generally not appropriate for managing acute/episodic pain.  Long-acting opioids may be considered for patients with chronic pain as part of a comprehensive, multimodal treatment plan if preferred pain management interventions have proven ineffective or insufficient to achieve functional outcomes.

Chronic pain has been variably defined but for our purposes is considered to be pain lasting > 3 months or past the expected time for normal wound healing.  Chronic pain is more likely to be associated with nervous system changes that alter pain perception and intrinsic pain regulatory mechanisms (involving production of endorphins and up/down regulation of various receptors and neurotransmitters) as well as changes in responses to pharmacologic interventions. In some cases, pharmacologic interventions (as in the case of opioid-induced hyperalgesia) may actually contribute to chronic pain by promoting maladaptive nervous system alterations of intrinsic pain regulatory mechanisms.

UpToDate and other sources can serve as an excellent reference regarding the evaluation of chronic pain. A thorough evaluation is needed to categorize the cause(s) of chronic pain and develop a corresponding treatment plan that is most likely to benefit the patient. One-size-fits-all treatments are less likely to produce desirable outcomes and more likely to be associated with undesirable side effects. Four broad categories of chronic pain are: Musculoskeletal, Neuropathic, Inflammatory and Mechanical (stretching or compressing/impinging). 

First line/preferred treatments may vary depending on the category/etiology of pain.  However, long-acting opioids are never considered the first line treatment for chronic pain of any type. In light of this, long-acting opioids require prior authorization to ensure preferred treatments have failed, are insufficient in achieving satisfactory functional outcomes (quantified though objective/validated tools/measures), or are contraindicated. If approved, the initial authorization will be for two months. As part of the prior authorization process, the safe use of long-acting opioids within a comprehensive, multimodal treatment plan also needs to be verified.

1)    All long-acting opioids (LAOs) require prior authorization. Patients being prescribed LAOs for a terminal illness or as part of end-of-life care will always be approved.

2)    LAOs are not covered for the treatment of fibromyalgia as the evidence does not support their use in this condition.

3)    LAOs are considered medically necessary subject to the coverage criteria below:

a)    Patient’s diagnosis must be documented on the prior authorization request.

b)    Patient must be being treated for chronic pain (pain persisting for greater than 3 months).

c)    Documentation of required workup and evaluation of category/etiology of chronic pain including following (check all that have been completed):

i)     Detailed history

ii)    Diagnostic testing

iii)   Specialist consultation(s)

iv)   Use of objective tools/measures to document functional status/outcomes

d)    Documentation of a comprehensive, multimodal treatment plan tailored to the results of the diagnostic workup and evaluation including following (indicate intervention(s) tried, date, length of trial, and functional response to treatment).

i)     Preferred non-pharmacological treatment modalities tried:

(1)  Behavioral interventions tried (e.g. counseling, biofeedback)

(2)  Self-help interventions (e.g. relaxation techniques, tailored exercise program, dietary modification)

(3)  Physical/manual/mechanical/electrical therapies (e.g. physical therapy, chiropractic therapy, osteopathic manipulative therapy, TENS)

ii)    Preferred non-opioid pharmacologic interventions tried:

(1)  Topical agents (including, but not limited to):

(a)  Capsaicin

(b)  Salicylate

(c)  Lidocaine

(2)  Systemic agents (including, but not limited to):

(a)  Antidepressants

(b)  Anticonvulsants

(c)  Muscle Relaxants

(d)  NSAIDs

(e)  Non-opioid analgesics

e)    Short-acting opioids

-       Procedural interventions such as:

-       Trigger point injections

-       Facet joint injections

-       Epidural injections

-       Other Joint injections

-       Botulinum toxin injections

-       Surgery

4)    Approval will require adequate trials (minimum 8 weeks) of at least:

a)    Three (3) non-pharmacologic modalities AND

b)    Three (3) non-opioid medication classes AND

c)    One (1) procedural intervention to be documented AND

d)    Significant functional improvement (> 30%) must be documented using a validated instrument in response to short-acting opioids AND

e)    If there is significant functional improvement (> 30%) to short-acting opioids but functional limitations associated with breakthrough pain, frequency of breakthrough pain and specific limitations must be documented.

5)    Documentation of treatment plan goals (updated upon reauthorization) which includes:

a)    The functional pain scale(s) used to determine baseline pain and function as well as response to treatments;

b)    Realistic goals for pain and function (e.g. pain may persist while function has improved) and when treatment will be stopped;

c)    Consequences of lost medication;

d)    Consequences of obtaining controlled substances from other prescribers;

e)    Member agreement to use only one pharmacy.

6)    Prescriber must attest to ALL of the following:

a)    Screening for high risk of opioid misuse using a validated screening tool is negative (such as DIRE > 13, ORT < 8, or SOAPP-R < 18);

b)    An Opioid Treatment Agreement signed by both the patient and prescriber is on file;

c)    Will check the Arkansas Prescription Monitoring Program (PMP) prior to each LAO prescription written;

d)    Benefits and potential harms of opioid use have been discussed with patient. In addition, risks of combining opioids with other central nervous system(CNS) depressants such as benzodiazepines, alcohol, other sedatives, skeletal muscle relaxants, illicit drugs such as heroin, or other opioids have been discussed with the patient;

e)    If patient has a high-risk condition stated in the CDC guidelines (e.g. sleep apnea or other causes of sleep-disordered breathing, patients with renal or hepatic insufficiency, older adults, pregnant women, patients with depression or other mental health conditions, and patients with alcohol or other substance use disorders) prescriber attests to discussing heightened risks of opioid use;

f)     Prescriber has ordered and reviewed a urine drug screen (UDS) or appropriate drug testing through an in-network laboratory;

g)    If being treated for chronic, moderate to severe, neuropathic pain, document the following:

i)     Type/cause of neuropathy;

ii)    Unless contraindicated, patient has not exhibited an adequate response to a minimum 8 week trial of gabapentin or Lyrica (document dosage, duration, and date of trial); AND

iii)   Unless contraindicated, patient has not exhibited an adequate response to a minimum 8 week trial with a tricyclic antidepressant titrated to a therapeutic dose (document drug, dosage, duration, and date of trial); AND

iv)   Prior to the start of therapy with the LAO, the patient has had a favorable response (> 30%) to a minimum 8-week trial of a short-acting opioid (document drug, dosage, duration, and date of trial) but there is unacceptable limitation of function associated with breakthrough pain. Breakthrough frequency and specific limitations must be documented.

7)    For new starts, requested opioid medication must be converted to daily morphine equivalent dose (MED). Maximum quantity approved will be 90mg MED.


LAOs will be re-authorized for 6 months with documentation/attestation of ALL of the following:

·         Treatment goals are defined, including estimated duration of treatment;

·         Treatment plan includes the continued or previous use of three (3) non-opioid pharmacologic agents;

·         Treatment plan includes use/trial of at least three (3) non-pharmacologic treatment modalities;

·         Patient demonstrates meaningful improvement in pain and function in response to LAOs using a validated instrument (such as BPI interference scale, BPI intensity scale, VR-12, RMDQ, or PHQ-8);

·         Patient has been screened for substance abuse/opioid misuse/dependence using a validated instrument (such as ABC > 3, PDUQ-p > 10, COMM > 9, high PADT or high PMQ);

·         If not currently in tapering protocol, provide rationale for not tapering or discontinuing opioid;

·         Prescriber has identified concurrently prescribed controlled substances from state prescription monitoring program (PMP), if any;

·         If used in patients with medical comorbidities or is used concurrently with a benzodiazepine or other drugs that could potentially cause drug-drug interactions, the prescriber has acknowledged that they have completed an assessment of increased risk of respiratory depression;

·         Requested opioid medication must be converted to daily morphine equivalent dose (MED). If quantity is greater than 90 MED, please provide detailed documentation noting why requested dose is required.


In the 1980s and early 1990s, numerous governmental (e.g., US Department of Health and Human Services) and nongovernmental (e.g., World Health Organization) bodies began to recognize pain control as an integral part of patient-centered care. In 1995, amidst these worldwide concerns of providers in managing pain, the American Pain Society presented the idea of evaluating pain as a vital sign, hoping that in elevating pain management to that level, it would become properly evaluated and managed. This hope was affirmed when, in 1999, the Veterans Health Administration (VHA) began a new initiative which measured and documented patients’ self-reporting of pain in their electronic medical records. This initiative, called “Pain as the 5th Vital Sign,” required the use of a 1-10 Numeric Rating Scale (NRS) for all clinical encounters. Separately, when the Joint Commission on Accreditation of Health Care Organizations (JCAHO) recommended pain assessments be conducted for all patients, pain measurement spread across the country very quickly. 

As healthcare providers adopted this approach, the result was a greater focus on pain management but there were also some unintended consequences. First, providers began prescribing more pain medications (including opioids) to minimize pain and improve their pain treatment scores. In the past two decades, opioids have been widely prescribed for chronic non-cancer conditions such as back pain, osteoarthritis, fibromyalgia, and headache. Between 1999 and 2010, the amount of prescription opioids sold in the United States nearly quadrupled, yet there has not been a similar change in the amount of pain that Americans report.  Strikingly, despite a 104% increase in opioid analgesic prescriptions in the U.S. (from 43.8 million in 2000 to 89.2 million in 2010) no improvements in disability rates or health status measures of opioid users has been demonstrated. However, diversion, misuse, and deaths from prescription opioids – drugs such as oxycodone, hydrocodone, and methadone – have also quadrupled in that same timespan. Each year the reports of overdoses from abused and diverted prescription opioid pain relievers become more ominous and the term “opioid crisis” has become a fixture in both healthcare and national news settings.

The role of opioids have clearly expanded beyond one that is safe and appropriate in many cases. In fact, opioids often ultimately contribute to the problem they were intended to solve. It is important for a health plan to have a comprehensive strategy that makes alternative sources of pain relief available to its’ membership and provider network in order to effectively manage pain but also afford some measure of protection from the misuse, overuse, and abuse of prescription opioids.

Program Objectives

The objectives of the QualChoice Comprehensive Pain Management Strategy include the following:

·         Improve Quality of Life;

·         Eliminate barriers to effective pain management therapy;

·         Focus on goals related to functional improvement/restoration (which are more objective and relevant than pain scores—especially when there are no physiologic signs consistent with elevated pain scores);

·         Set realistic goals in managing chronic, non-cancer pain;

·         Education;

·         Reduce use of short-term opioids in treating acute pain and reduce use of long-term opioids in treating chronic pain.

Strategy Components

1.    Provider Education – QualChoice is taking the opportunity to address the opioid crisis by providing important educational information in each of our Provider Newsletters. Information provided will touch on Prescription Drug Monitoring Programs (PMDPs), Guidelines for prescribing opioids for chronic pain, and the risk of addiction, abuse and misuse of opioids. In addition, as trends in prescribing change and new information comes available, we will continue to provide information to our provider network.

2.    Member Education – QualChoice is also providing members with educational material in newsletters regarding the use, misuse, and abuse of prescription opioids.  These topics include Opioid Safety Principles for Patients and Caregivers, Empty the Medicine Cabinet, and Prescription Opioids: What You Need to Know.

3.    Non-Pharmacologic Options- When thinking of pain management, many people immediately think of medication treatment as the first option.  However, there are a number of non-pharmacologic options that can be very effective for pain sufferers.  QualChoice promotes the appropriate use of these non-pharmacologic options and creates plan designs that eliminate barriers to their use. Some of these options are highlighted below.

a.    Physical Therapy/Occupational Therapy – These services are covered if ordered (prescribed) by a physician or chiropractor and provided by a licensed physical therapist, licensed physical therapy assistant supervised by a licensed physical therapist, licensed occupational therapist, or licensed occupational therapy assistant supervised by a licensed occupational therapist. Physical and occupational therapy services require a plan of care signed by the therapist and physician. Re-evaluation is allowed every twelve (12) visits, or if there is significant change in the patient’s status, such as a significant new symptom.  Some physical therapies, if effective, may be used on an ongoing basis by patients with appropriate patient education. TENS and iontophoresis are both examples of therapies that could be initiated by a physical therapist and continued at home if effective.

                       i.    Transcutaneous Electrical Nerve Stimulators (TENS) – These devices are considered necessary durable medical equipment (DME) when used as an adjunct or as an alternative to the use of drugs in the treatment of acute post-operative pain in the first 30 days after surgery or chronic, intractable pain not responsive to other methods of treatment. After a one-month trial period, continued TENS treatment may be considered medically necessary if the treatment significantly alleviates pain and if the attending physician or physical therapist documents that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time. If the TENS unit produces incomplete relief, further evaluation with percutaneous electrical nerve stimulation (PENS) may be indicated

                      ii.    Iontophoresis – Iontophoresis is a form of transdermal drug delivery that utilizes electrical current to drive or push ionized drugs through the skin’s outermost layer which is typically the main barrier to drug transport.  It has been used for decades and is often an attractive option in pain management. Advantages include that it is virtually painless when properly applied, provides an alternative to injections, is non-invasive, and allows medications to be delivered directly to the treatment site. It does require pre-authorization.

b.    Chiropractic Care – Chiropractic services are covered, although some services may require pre-payment review.

c.    Behavioral Health – There are a number of behavioral health services that offer non-pharmacological approaches to pain management. QualChoice promotes the use of these services for our members when appropriate to help better manage chronic pain. Some of these services are briefly described below.

                           i.     Psychosocial Services – Understanding and managing the thoughts, emotions, and behaviors that accompany the discomfort can help you cope more effectively with your pain and can actually reduce the intensity of your pain.  This can involve developing skills to help you find new ways to think about pain, develop additional coping skills, and learning relaxation techniques, for example.

                          ii.     Cognitive Behavioral Therapy – Cognitive behavioral therapy (CBT) is a form of talk therapy that helps people identify and develop skills to change negative thoughts and behavior. By changing their negative thoughts and behaviors, people can change their awareness of pain and develop better coping skills, even if the actual level of pain stays the same. The goals of CBT for pain are to reduce pain and psychological distress and to improve physical and role function by helping individuals decrease maladaptive behaviors, increase adaptive behaviors, identify and correct maladaptive thoughts and beliefs, and increase self-efficacy for pain management. CBT requires pre-authorization.

                        iii.     Hypnotherapy – Hypnotherapy may be effective in the management of certain types of pain.  Hypnotherapy or meditation therapy provided as part of psychotherapy under the direction of a network practitioner is covered when determined to be appropriate for the patient’s diagnosis. Hypnotherapy does require pre-authorization.

4.    Pharmacologic Options – While non-pharmacologic options are proven and effective, there may be a time and place for drug therapy in the treatment of pain. However, there are multiple options outside of prescription opioids. QualChoice designs our formularies and utilization management edits to encourage and support the use of non-opioid medications in the treatment of pain. Both prescription and non-prescription (over-the-counter) options exist and can be used effectively in managing pain. Some of these categories of drugs are highlighted below, along with utilization management edits used to help ensure appropriate utilization.

a.    Acetaminophen – Acetaminophen is one of the most widely-used over-the-counter (OTC) medications worldwide. Most acetaminophen is sold OTC (80%), while the remaining 20% is sold in prescription combination products. Acetaminophen (brand name Tylenol) provides predictable, if modest, pain relief, and is often recommended as a first-step treatment. An exhaustive review of the literature found that the overall risk of adverse events was the same for acetaminophen and placebo when given in clinical trials. However, the primary risk with acetaminophen is hepatotoxicity; acetaminophen liver damage is the leading cause of drug-induced acute liver failure in the U.S. The Food and Drug Administration (FDA) recommends that the total adult daily dose of acetaminophen should not exceed 4g/day in patients without liver disease. As a result, QualChoice implemented edits at the point-of-sale that limit the total daily dose of prescription medication containing acetaminophen to a maximum of 4g/day. If a prescription is attempted to be filled in amounts exceeding 4g/day, the claim will reject with a rejection message to the pharmacist of “Exceeds total daily dose of 4g/day.”

b.    Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) – NSAIDs have analgesic, anti-pyretic, and anti-inflammatory properties. They are moderately effective in reducing pain from a variety of conditions. While most studies compare an NSAID with a placebo, no consistent evidence shows that any NSAID confers greater analgesic efficacy than any other, at equipotent doses. The most serious NSAID side effects involve the gastrointestinal (GI) tract, heart, and kidneys. In patients at high risk for GI bleeding, NSAIDS may need to be avoided. Most generic NSAIDs are available to QualChoice members at low member cost share with no utilization management edits in place.

c.    Antidepressants – Some antidepressants exhibit analgesic properties, possibly via indirect effects on opioid receptors or interactions with N-methyul-D-aspartate (NMDA) receptors. Their analgesic actions do not depend on antidepressant activity, and antidepressants are equally effective in patients with and without depression. While analgesia may occur at lower doses and sooner than antidepressant activity, maximum efficacy may require high doses and treatment of potentially lengthy duration.

Tricyclic antidepressants (TCAs) and Serotonin/noradrenaline reuptake inhibitors (SNRIs) are effective for a variety of neuropathic pain syndromes. TCAs include drugs such as amitriptyline and desipramine. There are no significant differences in efficacy between the different TCAs. SNRIs include duloxetine and venlafaxine. Duloxetine has labeled indications to treat diabetic neuropathy, musculoskeletal pain, osteoarthritis, and fibromyalgia. Venlafaxine has been shown to be effective in patients with diabetic neuropathy. Selective serotonin reuptake inhibitors (SSRIs) have also been used to treat neuropathic pain, with paroxetine and citalopram showing the superior results compared to placebo.

d.    Anticonvulsants – The increasing use of antiepileptic drugs (AEDs) for neuropathic pain is based on their ability to reduce membrane excitability and suppress abnormal discharges in pathologically altered neurons. The exact mechanism of action for their analgesic effect, however, is unclear. AEDs are used to treat neuropathic pain especially lancinating (i.e. episodic shooting, stabbing, or knife-like) pain from peripheral nerve syndromes. The two most common products used are gabapentin (Neurontin) and pregabalin (Lyrica). QualChoice requires a minimum 60-day trial of gabapentin before authorizing Lyrica for use to treat neuropathic pain.

e.    Topicals – Several topical agents are often used in the treatment of pain. These include capsaicin, salicylate products, topical NSAIDs, and Lidocaine.  While the evidence for efficacy of many of these products is mixed, some members experience pain relief from their use. They are available in creams, ointments, and some are available in patches. Many of these are covered per their labeled indication but may have quantity limits per prescription and/or may require prior authorization (PA).

f.     Triptans and Calcitonin gene-related peptide (CGRP) inhibitors are  classes of drugs used to treat migraine headaches. These products are now available in generic form. Most are covered by QualChoice, with some requiring step therapy (using a less expensive generic triptan first) and all have quantity limits per prescription fill.

g.    Skeletal Muscle Relaxants – Skeletal muscle relaxants are commonly used to treat spasticity from upper motor neuron syndromes and muscular pain or spasms from peripheral musculoskeletal conditions. Most are approved for the treatment of musculoskeletal conditions with only a very few approved for the treatment of spasticity. These agents should be relegated to short-term use only. They include products such as baclofen, carisoprodol, chlorzoxazone, cyclobenzaprine, methocarbamol, tizanidine, and metaxalone. QualChoice utilizes a step therapy approach before approving metaxalone, requiring a trial of at least two (2) other skeletal muscle relaxants in the past 90 days.

h.    Opioids – Opioids are often used to treat cancer pain and in end-of-life care. Arkansas legislation requires any prior authorization request for pain medication for patients with these conditions be approved. QualChoice is in compliance with that statute.

While opioids have been used in the treatment of chronic, non-cancer pain, they are not the best choice in these situations. Research shows that chronic pain is predominantly a central processing problem rather than a peripherally generated pain stimulus/signal. Chronic use of opioids interferes with central pain processing in a manner that actually amplifies pain sensitivity. This is not a concern for patients with a terminal diagnosis but is a tremendous disservice to patients without a terminal diagnosis. 

All-cause mortality is substantially higher for patients with chronic pain on opioids than for patients with chronic pain not on opioids. Since the research shows mortality is higher and chronic pain control is no better, it is becoming increasingly clear there is no clinical justification for chronic opioid use to manage pain for patients without a terminal diagnosis. 

As outlined above, we offer a number of different options to treat chronic, non-cancer pain outside of opioids. As payers, we cannot force providers to change inappropriate prescribing practices overnight. However, we have already created policies that limit overprescribing of short-acting opioids for acute problems.  These policies are consistent with widely recognized, nationally accepted pain management guidelines. This is the first step in reducing the likelihood of becoming a chronic opioid user and we are already seeing positive changes as a result of this. In addition, by reviewing and updating of our policies and processes, it is our intent to create a very high barrier for approval of long-acting and long term opioids for any patients without cancer or another terminal diagnosis. 

In lieu of the aforementioned “opioid crisis”, we have implemented a number of different edits to limit and control the use of opioids, in an effort to prevent some of the problems associated with long-term opioid use and redirect to alternative therapies.

Both concurrent and retrospective drug utilization review (DUR) edits are utilized to ensure safe and appropriate use of opioids and related drugs. A summary of these edits is provided below.

Concurrent DUR (cDUR) Edits

§  Therapy Dose Check (High Dose Acetaminophen) – checks for claims where daily acetaminophen exceeds 4gm/day

§  Opioid/prenatal vitamin drug-drug interaction

§  Opioid/Medication Assisted Treatment concurrent use

§  Opioid/benzodiazepine drug-drug interaction

§  Drug Enforcement Agency (DEA) prescriber edits

§  Cumulative Daily Dose/Morphine Milligram Equivalent (MME) Dose Limits (90 MME/day)

Retrospective DUR (rDUR) Edits

§  Daily screen of clinical opportunities to intervene on overuse, duplicate therapy, drug-drug interactions, doctor shopping, and pharmacy shopping

§  Intensive Case Management – Daily screening (MME per day and exceeds numbers of prescriber and pharmacy threshold) that trigger Pharmacist Consultants/Intensive Case Management intervention

Short-Acting Opioid (SAO) Point-of-Sale (POS) Edits

§  New to Therapy members (any member with no history of an opioid within the previous 120 days)

·      QL = 49 MME/day

·      No more than 7 day supply (DS) per prescription and cannot receive more than 2 prescriptions within a 60 day period

§  Treatment-experienced members (any member with an opioid prescription within previous 120 days)

·      QL = 90 MME/day

·      No more than 2 prescriptions (for max 30 DS) within 60 day time period

§  Prior Authorization (PA) required to exceed these limits with following criteria:

·      The prescriber certifies there is an active treatment plan that includes, but is not limited to, a specific treatment objective and the use of other pharmacological and non-pharmacological agents for pain relief as appropriate AND

·      The prescriber certifies 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 exists between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances

Long-Acting Opioids (LAO) Limits:

§  Currently under consideration and will be implemented soon

5.    Substance Use Disorder – QualChoice understands the need for substance use disorder treatment and provides coverage for a variety of treatments. These may include inpatient and outpatient therapy (when approved) as well as medication assisted treatment (MAT). Specific policies regarding both outpatient and inpatient therapy for mental health and substance use disorder are available on the QualChoice website.

Medication assisted treatment (MAT) is also covered, with specific policies for Vivitrol (naltrexone) injection and buprenorphine/naloxone combination products also available on the QualChoice website. For members using buprenorphine/naloxone combination products, we utilize point-of-sale (POS) edits to stop members from using concurrent opioids and to identify members using concurrent benzodiazepines to confirm intent with prescriber.


1.    Bateman, B., Avorn, J., Choudhry, N.K., et al.  Managing Pain Without Overusing Opioids.

2.    Ehde, D.M., Dilworth, T.M., Turner, J.A. Cognitive-Behavioral Therapy for Individuals With Chronic Pain.  American Psychologist 2014; 69(2), 153-166.

3.    Clauw, Daniel. Hijacking the Endogenous Opioid System to Treat Pain. Pain. 2017; 158(12):2283-2284.

4.    Agency for Healthcare Research and Quality. The effectiveness and risks of long-term opioid treatment of chronic pain. 2014.

5.    Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. The Clinical journal of pain. 2014; 30(7):557-564.

6.    Juurlink DN and Dhalla IA. Dependence and Addiction During Chronic Opioid Therapy. J Med Toxicology. 2012; 8(4)393-399

7.    Franklin, Gary M. Opioids for Chronic Noncancer Pain - A position paper of the American Academy of Neurology. Neurology. 2014; 83(14):1277-1284.

8.    Bottemiller, Shelby. Opioid-Induced Hyperalgesia: An Emerging Clinical Challenge. US Pharm. 2012;37(5):HS-2-HS-7.

9.    Lee M, Silverman S, Hansen H, et al. A Comprehensive Review of Opioid-Induced Hyperalgesia. Pain Physician. 2011; (14):145-161.

10. Yi P and Pryzbylkowski P. Opioid Induce Hyperaglesia. Pain Medicine. 2015; (16):S32-S36.

11. Vella-Brincat J and Macleod AD. Adverse Effects of Opioids on the Central Nervous Systems of Palliative Care Patients. J Pain & Pall Care Pharmacotherapy. 2007; 21(1):15-25.

12. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients with Chronic Back Pain of Hip or Knee Osteoarthritis Pain—The SPACE Randomized Clinical Trial. JAMA. 2018; 319(9):872-882.

13. Peltz G and Sudhoff TC. The Neurobiology of Opioid Addiction and the Potential for Prevention Strategies. JAMA. 2018; 319(20):2071-2072.

14. Argoff CE and Silverstein DI. A Comparison of Long- and Short-Acting Opioids for the Treatment of Chronic Noncancer Pain: Tailoring Therapy to Meet Patient Needs. Mayo Clin Proc. 2009: 84(7):602-612.

15. Dowell D, Hargerich TM and Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—United States 2016. MMWR. 2016: 65(1):1-49.

16. Moberg, Kirk. The Role of Managed Care Professionals and Pharmacists in Combating Opioid Abuse.  AM J Manag Care. 2018; 24:S215-S223.

17. Kominek, Courtney. Current and Emerging Options to Combat the Opioid Epidemic. Am J Manag Care. 2018; 24:S207-S214.

18. Hagemeier, NE. Introduction to the Opioid Epidemic: The Economic Burden on the Healthcare System and Impact on Quality of Life. Am J Manag Care. 2018; 24:S200-S206.

19. Fatodu H, Garofoli M, Johnson GL, et al. A Dialogue on Opioid Misuse and Abuse: Best Practices for Population Health. Am J Manag Care. 2018; 24(12):S251-S261.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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