Opioid medications restricted under Quantity Limitations (QL) Program — Point32Health

Initial criteria

• The patient is diagnosed with sickle cell-related, cancer-related, or end-of-life pain OR ALL of the following:
• The patient has a diagnosis of Pain
• The patient signed a pain agreement consistent with the American Academy of Pain Management guidelines
• The analgesic is prescribed by or in consultation with a pain specialist, addiction specialist, palliative care specialist, hematologist/oncologist, physiatrist, rheumatologist, or headache specialist (board certified) OR there is a plan for the patient to be referred to such a specialist OR rationale provided why the patient is not a candidate to see a specialist
• The risks of use of a high dose schedule II, III, or IV analgesic use (e.g., tolerance, dependence, respiratory depression, cognitive impairment) have been discussed with the patient
• The provider has a plan to monitor for signs of misuse, abuse, and addiction during therapy
• The provider has a taper plan in place or rationale as to why a dose taper is not appropriate at this time

Approval duration

≤ 1 year