Opioid management program and pain management alternatives

Opioid management program for Commercial, MassHealth, and Exchange plans 

Opioid painkillers provide needed relief to those with acute or chronic pain. But given their potential for harm, and the very
real–and pervasive–problem of misuse and abuse, ensuring appropriate use is more critical now than ever before. Our standard opioid management program is aligned with the "Guideline for Prescribing Opioids for Chronic Pain" issued by the Centers for Disease Control and Prevention (CDC) in March 2016 and contains the following features:

  • Limit days supply
    The length of the first fill (when appropriate) will be limited to 3 days for members 19 and under or 7 days for members over 19 years of age for immediate release, new, acute prescriptions for plan members who do not have a history of prior opioid use, based on their prescription claims. A physician can submit a prior authorization (PA) request if it is important to exceed the seven-day limit.
  • Limit quantity of opioids
    The quantity of opioid products prescribed (including those that are combined with acetaminophen, ibuprofen or aspirin) will be limited up to 90 Morphine Milligram Equivalent (MME)  per day (based on a 30-day supply). Prescribers who believe their patient should exceed CDC Guideline recommendations can submit a PA request for up to 200 MME per day unless minimum FDA-labeled strength/dose/frequency exceeds 200 MME per day. Quantities higher than that would require an appeal. Opioid products containing acetaminophen, aspirin, or ibuprofen will be limited to 4 grams of acetaminophen or aspirin, and 3.2 grams of ibuprofen per day.
  • Require step therapy
    Use of an immediate-release (IR) formulation will be required before moving to an extended-release (ER) formulation, unless the member has a previous claim for an IR or ER product, or the prescriber submits a PA.

When patients fill a prescription for an opioid (a covered drug that is a narcotic substance contained in U.S. Drug Enforcement Administration Schedule II), they may choose to obtain a fill in a lesser quantity than the full amount prescribed.  If they do, they may then choose to later obtain the remainder of the prescribed fill.  They will not be responsible for any copayment amount beyond the amount that would normally apply if they obtained the entire fill at once.

Pain management alternatives to opioid products for Commercial, MassHealth, and Exchange plans

If you are interested in pain management alternatives to opioid products for your patients, there are many non-opioid medications and treatments available. These include, but are not limited to, those listed below.

Non-opiate medication treatment options (Please note that some medications require PA or may have other utilization management restrictions):

  • NSAIDs
  • Topical Analgesic
  • Cox-II Inhibitors
  • Skeletal Muscle Relaxants
  • Anti-Depressants
  • Anti-Convulsants
  • Corticosteroids

Please refer to our formulary for further information about our prescription drug formulary and prior authorization requirements.

Non-medication treatment modalities:

  • Chiropractic care.
  • Physical therapy services
  • Behavioral health providers with pain management-related specialties, such as cognitive behavioral therapy, pain management and treatment of chronic pain. 

These services may require prior authorization or may be subject to benefit limitations.

Additional medications and treatments are available which may also serve as pain management alternatives to opioid products. These include other medications, certain other types of therapies, treatment by certain types of non-behavioral health specialists, certain types of surgery, and certain types of injections.