codeine — Medical Mutual

Initial criteria

• The member’s pain has been evaluated by one or more physicians who specialize in treatment of the area where the perceived pain is located or a pain specialist; AND
• If the member is taking over 80 Morphine Equivalent Dosage of the opioid requested, provider must verify the dose has been titrated and the lowest appropriate dose is being used; AND
• The prescriber attests that they have reviewed controlled substance medication history by running an Ohio Automated Rx Reporting System (OARRS) Report (or respective prescription monitoring program in the provider’s state of practice if available) and they will continue to check OARRS (or respective prescription monitoring program in the provider’s state of practice) at a minimum every 3 months; AND
• If the patient is taking a benzodiazepine or muscle relaxant concurrently, the prescriber is aware of the risk versus benefit of the combination and attests continuation of concurrent therapy is clinically necessary; AND
• The provider must have a pain management contract with the patient; AND
• The patient has been thoroughly evaluated and assessed on a regular basis by the provider to determine pain levels, quality of life, medication effectiveness, and an evaluation of possible addiction (provider must supply information such as patient charts and documentation upon first fill); AND
• The prescriber provides a treatment plan including the use of non-opioid analgesic and/or non-pharmacological interventions and expected opioid treatment duration; AND
• Realistic benefits and known risks (e.g. addiction, overdose) of opioid therapy have been discussed with the patient and expected benefits for pain and function are anticipated to outweigh risks to the patient; AND
• Patient has been counseled on safe storage and disposal of opioids by prescriber; AND
• Patient has been counseled on the dangers of combining opioids with alcohol or other CNS depressants; AND
• The provider verifies no concurrent substance abuse treatments are being prescribed (examples include but not limited to Suboxone (buprenorphine/naloxone), Vivitrol (naloxone), oral naloxone, buprenorphine)

Reauthorization criteria

• A response to therapy is required for continuation of therapy

Approval duration

1 year