Opioid Prescribing Limits - Effective October 1, 2016

Date: 09/12/16

Opioid Prescribing Limits – Effective October 1, 2016

Managed Health Services (MHS) is implementing new prescribing limits for opioid medications. The limits are in response to the opioid epidemic that is sweeping our nation. MHS has worked with the State Medicaid program to determine a set of common criteria that balances the clinical need for opioid pain medications, while helping to minimize the number of members on opioid medications for longer than clinically needed. This was a collaborative effort to create limits that support both CDC Guideline for Prescribing Opioids for Chronic Pain and the Indiana Pain Management Prescribing Rules.

Opioid Plan Restrictions – Note differences for Opioid Naïve and Chronic Opioid users

• Opiate Naïve members (Members with claim history showing less than 90 day supply of opioids in last 120 days)
  • Daily morphine equivalence limit of 60 MED (see chart below)
  • Limit of 7 day supply of short acting opioid. May have an additional 7 day supply within a rolling 45 day window. PA will be required for prescriptions with greater than 7 day supply, or for greater than 14 days of total opioid therapy in a rolling 45 day window.
  • PA for all long acting opioids
    • All long acting opioids will require a PA regardless of the quantity or day supply.
    • Preferred opioids must be tried first unless there is a clinical reason to use non-preferred long acting opioids
  • Limit of 1 long acting and 1 short acting agent at one time

• Chronic Opioid users (members with claim history showing greater or equal to 90 day supply of opioids in last 120 days)
  • Limit 1 long acting and 1 short acting agent at one time
  • 60 MED and 7 day limits do not apply to chronic opioid users

*Prior Authorization is available when there is medical necessity to prescribe opioids longer than the limits would allow.

• PA Criteria:
  • Diagnosis of moderate to severe chronic pain; and
  • Failure of at least two non-opioid ancillary treatments (NSAIDs, anticonvulsants, antidepressants, etc. at maximum tolerated doses); and
  • If request is for long acting agent, must have failed mono-therapy with short acting agent
  • Cancer, palliative care and sickle cell crisis will be excluded from the opioid limits

Morphine Equivalence Chart for Common Short Acting Opioids:

Drug Name and Strength	Max Daily Tabs to be ≤ 60 MED	Drug Name and Strength	Max Daily Tabs to be ≤ 60 MED
Hydrocodone/APAP 5mg/325mg	12 tabs	Oxycodone/APAP 7.5mg/325mg	5 tabs
Hydrocodone/APAP 7.5mg/325mg	8 tabs	Tramadol 50mg	8 tabs (FDA Max Dose 400mg/day)
Hydrocodone/APAP 10mg/325mg	6 tabs	Oxycodone (IR) 5mg	8 tabs
Oxycodone/APAP 5mg/325mg	8 tabs	Tylenol #3	12 tabs