Prior Authorization Conditions for High Dose Narcotics and Long and Short Acting Narcotics
Website Form – www.highmarkhealthoptions.com
Submit request via Fax: 855-476-4158
Criteria apply to all short and long acting opioids. Additional clinical criteria may apply, see the PDL.
Covered Conditions:
 Chronic pain that is not related to a malignancy.
 Chronic pain related to cancer will be an excluded diagnosis. Patients will not need to meet the below
requirements if they have active therapy or are post-surgery.
Prior Authorization will be required when any of the following apply:
 The requested product is a long acting opioid analgesic
 The total quantity of Oxycodone 15 mg exceeds 240 units a year
 The total quantity of Oxycodone 20 mg exceeds 120 units a year
 The total quantity of Oxycodone 30 mg exceeds 60 units a year
 Short-acting quantity may not exceed 120 per 30 days with a total of 720 short-acting units a year
General Requirements
 For all prior authorization requests, the following criteria must be met:
o Patient must be at least 12 years of age
o Patient has a diagnosis of moderate to severe pain
o A pain assessment tool (e.g. a numeric or visual analog scale) completed by the provider is submitted
with each request.
 For reauthorization, prescriber must provide an updated pain assessment and indicate the patient
has had an improvement in pain and function. If patient has not experienced an improvement in
pain and function, prescriber must provide a treatment plan and rationale for continuation of
opioid therapy.
o A signed provider-patient pain management contract is submitted
o The provider has reviewed the patient’s Prescription Monitoring Program (PMP) data for the member’s
controlled substance prescription history. This is a requirement for non-LTC patients.
o Documentation that patient has tried and was unable to achieve relief with non-pharmacologic pain
management modalities (e.g. behavioral, cognitive, physical and/or supportive therapies) or is using these
treatments along with opioid therapy
o Documentation that patient has tried and was unable to achieve relief (or has a contraindication) to two
(2) or more non-opioid analgesics (e.g. acetaminophen, NSAIDs, antidepressants, anticonvulsants)
o To promote coordination of care and patient safety, medical necessity rationale will be required in
situations when a member is taking an opioid and benzodiazepine concurrently. Members with a seizure
diagnosis are exempt from this requirement.
o A urine drug screening (UDS) has been completed within the previous six (6) months and results are
consistent with current treatment and devoid of illicit substances. If the UDS returns unexpected results,
prescriber must provide treatment plan and rationale for continuation of opioid therapy.

For short-acting opioid analgesics exceeding the quantity limit, all of the following must be met:
o Must have documentation that pain is inadequately controlled at the current quantity limit; AND
o Pain is inadequately controlled by other short-acting opioids or the patient has a history of intolerance or
a contraindication to alternative short-acting opioids; AND
o If the two previous requirements both apply to the patient, the provider has evaluated whether or not the
patient’s pain may be more appropriately controlled on a long-acting opioid
Revised 1/2017

For long acting opioid analgesics, all of the following must be met:
o Must be for ongoing continuous therapy, not on an as needed basis; AND
o Patient must have tried and failed at least one (1) short-acting opioid
Authorization Durations: When criteria are met, authorization will be granted for up to six (6) months.
Patients with a diagnosis of active cancer (e.g. active therapy, post-surgery) will be granted a 12 month
authorization. In situations when the request is deemed not medically necessary and the patient is concurrently
taking an opioid and benzodiazepine, a three (3) month authorization will be granted to allow for tapering of the
benzodiazepine.
References:
1. Dowell D, Haegerich TM, Chou R et al. CDC guideline for prescribing opioids for chronic pain-United
States, 2016. MMWR Recomm Rep 2016;65:1-49.
2. Center for Medicaid and CHIP services. CMCS information bulletin: best practices for addressing
prescription opioid overdoses, misuse and addiction. Baltimore MD: U.S. Department of Health and
Human Services, 2016
3. Chou R, Gordon DB, Leon-Casasola OA. Guidelines on the management of postoperative pain. J
Pain.2016;17(2):131-57.
4. Volkow ND, McLellan AT. Opioid abuse in chronic pain: misconceptions and mitigation strategies. N
Engl J Med. 2016;374:1253-63.
5. Lader M, Tylee A, Donoghue J. Withdrawing benzodiazepines in primary care. CNS Drugs. 2009; 23:1934.
6. Greller H, Gupta A. In: Benzodiazepine poisoning and withdrawal. In UpToDate, Waltham, MA.
(Accessed on October 18, 2016).
7. Moulin DE, Clark AJ, Gilron I et al. Pharmacological management of chronic neuropathic pain—
consensus statement and guidelines from the Canadian Pain Society. Pain Res Manage. 2007; 12(1):1321.
8. O’Connor AB, Dworkin AB. Treatment of neuropathic pain: an overview of recent guidelines. Am J Med.
2009; 122:S22-S32.
Revised 1/2017
High Dose Narcotics and Long and Short Acting Narcotics
PRIOR AUTHORIZATION FORM
Please complete and fax all requested information below including any progress notes, laboratory test results, or chart
documentation as applicable to Health Options Pharmacy Services. FAX: 1-855-476-4158
If needed, you may call to speak to a Pharmacy Services Representative. PHONE: 1-844-325-6251
PROVIDER INFORMATION
Requesting Provider:
NPI:
Provider Specialty:
Office Contact:
Office Address:
Office Phone:
Office Fax:
MEMBER INFORMATION
Patient Name:
Health Options ID:
DOB:
DRUG INFORMATION
Medication:
Strength & Frequency:
Quantity:
Duration:
MEDICAL HISTORY
Diagnosis/diagnoses:
What is the suspected cause of pain (e.g. post-operative, neuropathic)?
Current Regimen
Proposed Regimen
(including medication, dose, frequency, duration)
(including medication, dose, frequency, duration)
Is a pain assessment tool that was completed by the prescriber attached?
Yes
No
For reauthorization:
 Is an updated pain assessment provided?
Yes
No
 Has the patient had an improvement in pain and function?
Yes
No
 If no, please provide a treatment plan and rational for continued use:_____________________________________
________________________________________________________________________________________________
Is a signed provider-patient pain management contract attached?
Yes
No
Has the provider reviewed the patient’s Prescription Monitoring Program (PMP) profile?
Yes
No
 If no, please explain:
Is the patient currently taking a benzodiazepine?
Yes, provide diagnosis: ___________________________
No
 If yes, will there be an attempt to taper off benzodiazepine therapy?
Yes
No
 If no, please provide clinical rationale for continuation while on opioid therapy:____________________________
Has a urine drug screen been completed within the previous six months?
Yes
No
 Were the results consistent with current treatment and devoid of illicit substances?
Yes
No
 If no, please provide treatment plan and rationale for continuation of opioid therapy: ________________________
________________________________________________________________________________________________
Please be sure to complete PAGE 2 of this prior authorization form.
Revised 1/2017
Non-pharmacologic and pharmacologic (including opioid and non-opioid) treatments tried/failed
Drug Name
Strength/ Frequency
Dates of Therapy
Status (Discontinued & Why)
ADDITIONAL SUPPORTING INFORMATION or CLINICAL RATIONALE
Prescribing Provider Signature
Revised 1/2017
Date