Medicaid’s Prior Approval Criteria for Opioid Analgesics Updated to Comply with STOP Act

Starting Jan. 2, 2018 clinical coverage criteria for opioid analgesics under Medicaid will be updated to comply with the quantity limits mandated by the Strengthen Opioid Misuse Prevention (STOP) Act the legislation signed into law by the Governor last summer.

Prior approval will be required for short-acting opioids for greater than a five-day supply for acute pain and seven-day supply for post-operative acute pain. Prior approval will be required for long-acting opioids for greater than a seven-day supply. This is a change from current criteria which requires prior approvals for greater than a 14-day supply for long- and short-acting opioid analgesics.

The prescribing provider may submit prior approval requests to NCTracks through the NCTracks portal or by fax. New opioid analgesic prior approval forms and revised clinical coverage criteria will be available on the NCTracks website.

Beneficiaries with diagnosis of pain secondary to cancer will continue to be exempt from prior approval requirements.


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