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short-acting opioids — United Healthcare

Post-surgical pain (excluding dental procedures)

Initial criteria

  • Member is opioid naïve, defined as not having filled an opioid in the past 120 days
  • Request is for greater than the supply limit and ALL of the following are met:
  • ONE of the following:
  • Cancer diagnosis OR End of life pain (including hospice care) OR Palliative care OR Sickle cell anemia OR BOTH of the following:
  • ONE of the following: Traumatic injury OR Post-surgical procedures (excluding dental procedures) OR Prescriber attests patient has received an opioid in the past 120 days
  • AND prescriber attests that based on the injury or surgical procedure performed the member requires greater than a 7-day supply of short-acting opioids to adequately control pain
  • AND if request is for 50 MME or greater, ONE of the following:
  • Diagnosis of cancer, end of life pain (including hospice care), palliative care, or sickle cell anemia OR Patient is currently at or exceeding 50 MME and prescriber attests patient has been on an opioid in the past 120 days OR ALL of the following:
  • Diagnosis associated with the need for pain management with opioids is documented
  • If used in patients with medical comorbidities or concurrently with a benzodiazepine or other drugs that may cause interactions, prescriber has completed an assessment of increased risk for respiratory depression
  • Prescriber has completed an addiction risk and overdose risk assessment
  • Prescriber attests the member requires more than 50 MME per day to adequately control pain (initial fill limited to 90 MME)
  • AND request does not exceed four grams of acetaminophen per day
  • Age-specific initial fill limits: Patients age ≤19 years – 3-day supply limit; age ≥20 years – up to 7-day supply limit; all ages initial fill limited to <50 MME

Reauthorization criteria

  • Authorization renewals may be determined based on previous claim/medication history, diagnosis codes, and/or automated claim logic verification per UnitedHealthcare policy

Approval duration

Cancer, end of life pain, palliative care, or sickle cell anemia: 24 months (quantity 9999). Members new to plan (<120 days coverage): 1 month. All other approvals: 1 month.