Effective: 08/18/2020 C4273-C, C10295-J Page 2 of 3
Will treatment be prescribed at lowest effective
dose?
☐ Yes ☐ No
Will treatment be reviewed within 1 - 4 weeks of
starting therapy AND with any dose escalation
AND re-evaluated every 3 months?
☐ Yes
☐ No
Was there review of state’s PMD/PDMP for controlled substances, with focus on opioid doses OR dangerous
combinations?
☐ Yes
☐ No
Was UDS reviewed prior to starting treatment?
☐ Yes ☐ No
Were results of UDS consistent with prescribed
controlled substances?
☐ Yes
No
Is there evidence of substance use disorder?
☐ Yes ☐ No
Was evidence-based treatment
arranged (for example MAT)?
☐ Yes ☐ No
N/A
Is request for FEMALE of reproductive age?
☐ Yes ☐ No
Was counseling provided about
opioid use during pregnancy
AND about NAS?
☐ Yes ☐ No ☐ N/A
Additional Clinical Criteria
Long Acting Opioids
Will member exceed 90 MME per day limit?
☐ Yes ☐ No
Was documentation submitted to
support exceeding recommended
limit?
☐ Yes
☐ No ☐ N/A
Was pain specialist consulted?
☐ Yes ☐ No
N/A
Is request for chronic pain?
☐ Yes ☐ No
Was treatment initiated with IR opioid for at least TWO weeks prior to considering ER/LA opioid?
☐ Yes ☐ No
Is request for Butrans
patch?
Yes No Is there documented need for opioid with lower risk for
abuse AND noted concern that member, or member’s
household is at risk for abuse and diversion?
☐ Yes ☐ No
Is request for non-formulary
agent?
Yes No Was there inadequate response OR intolerance to ALL
formulary LA opioids for 2 weeks?
Yes
☐ No
Is request for abuse-
deterrent product?
☐ Yes ☐ No
Is there documentation of trial and failure of Butrans
patch for at least 2 weeks?
☐ Yes
☐ No
Is there documentation to indicate NEED for abuse
deterrent product AND concern that member OR
member’s household is at risk?
Is request for methadone?
☐ Yes
☐ No
Is female member pregnant?
☐ Yes ☐ No ☐ N/A
Short Acting Opioids
Will member exceed 90
MME per day limit?
☐ Yes ☐ No
Was there documentation to support medical necessity
of exceeding recommended MME OR day supply limit?
Yes
No
N/A
Is request for non-formulary
short-acting agent?
☐ Yes
No
Was there inadequate response OR intolerance to ALL
formulary short-acting opioids?
☐ Yes ☐ No
Was documentation submitted supporting continued use of short acting agent beyond 30 days AND when
used in combination with long-acting agent?
☐ Yes ☐ No
Acute Pain - Pediatric Members <18 Years of Age
Is request for acute pain (post-dental procedure?
☐ Yes ☐ No
Was pain assessment
completed?
☐ Yes
☐ No
Has member AND their parent/guardian been screened for previous AND current opioid use?
☐ Yes ☐ No
Did provider check state’s PMD/PDMP for controlled
substances with focus on opioid doses AND
dangerous combinations?
☐ Yes ☐ No
Was concomitant use with BNZ
addressed, IF present?
☐ Yes ☐ No ☐ N/A
Will opioid therapy be used in COMBO
with APAP and NSAIDs, unless
contraindication is present for use of both?
☐ Yes ☐ No
Was COMBO therapy with APAP and
NSAIDs tried AND failed OR were there
contraindications present for use of both?
☐ Yes ☐ No
Is request for codeine OR tramadol?
☐ Yes ☐ No
Is member <12 years of age?
☐ Yes ☐ No
Is prescription limited to 8 – 12 tablets
☐ Yes ☐ No
Will IR opioids be prescribed at lowest effective dose AND not greater than expected pain duration?
(NOTE: ≤3 days is recommended by CDC. >7 days will rarely be required)
☐ Yes ☐ No
Renewal ONLY
Was there sustained improvement in
Pain OR Function?
☐ Yes ☐ No
Was tapering plan initiated to D/C treatment
of current medication?
Yes ☐ No ☐ N/A
Was UDS performed in past year?
☐ Yes ☐ No
State’s PMP was reviewed
AND verified (check that apply):
☐ Prescriptions from
other providers
☐ Benzodiazepines ☐ ER / LA use for
acute pain
☐ UDS consistent with prescribed
controlled substances
Is dose ≥50 MME per day?
☐ Yes ☐ No
Did provider offer Naloxone to member?
Yes
No
N/A
