Opioid-Related Clinical Prior Authorization Criteria Updates for September 1, 2020

Opioid-Related Clinical Prior Authorization Criteria Updates for September 1, 2020

VDP regularly updates the clinical prior authorization criteria. These updates are necessary to help align VDP drug policies and prior authorization approval criteria with the latest information available on drug information packets, the federal or state regulations. FirstCare will implement the following opioid prior authorization criteria revisions on Sept. 1, 2020, to align with the uniform opioid policy.
 
Opioid Policy Criteria
The Opioid Policy criteria will be implemented with the following:
  • Opioid naïve is defined as members who have taken opioids for a duration less than or equal to seven days in the prior 60-day period. For opioid naïve patients, FirstCare must require a one-time authorization for: 
    • An opioid prescription which exceeds a ten-day supply
    • A prescription for a long-acting opioid formulation
    • A claim in which the total daily dose of opioids exceeds 90 MME
  • For members who no longer meet the definition of opioid naïve, an authorization will be required if the total daily dose of opioids exceeds 90 MME. If approved, the authorization is for a six-month duration.
Opiate Over-Utilization Criteria
The Opiate Over-utilization criteria will be revised September 1, 2020. The criteria document was revised to include a question regarding cancer, sickle cell, palliative care, and hospice care diagnosis This change will align the prior authorization criteria with the new opioid policy.
 
For FirstCare clinical edits, please click here.

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