Qdolo — CareFirst (Caremark)
Pain associated with a terminal condition
Initial criteria
- For members age ≤ 19 years, initial opioid prescriptions for acute pain are limited to 3 days supply.
- For all opioids covered under this policy, morphine milligram equivalent (MME) daily threshold limits apply as specified (≤ 90 MME/day for initial up to 3 months, ≤ 200 MME/day post 3 months).
- Prescriptions exceeding the day supply or MME limit require prior authorization review based on diagnosis and clinical necessity.
Reauthorization criteria
- Continuation may be authorized if the member continues to have pain associated with cancer, sickle cell disease, terminal condition, or is under hospice/palliative care management.
- For chronic non-cancer pain, reauthorization requires documentation of continued need and lack of suitable alternatives.
Approval duration
Pain associated with cancer/sickle cell/terminal/palliative: 12 months; Chronic pain: 6 months; Acute pain: 1 month