While Tufts Health Together will be adopting MassHealth’s Unified Formulary on April 1 for Tufts Health Together, we will follow different thresholds for opioid dosage.
Tufts Health Together will be implementing a number of opioid clinical programs as part of the Unified Formulary. Please refer to the table below for these initiatives, their descriptions, and the implementation date. For more information, including authorization criteria, please refer to Opioids and Analgesics Medical Necessity Guideline.
|Quantity limits restrict opioid dosage forms to 90 morphine milligram equivalent (MME)/day or per the dosing listed in the FDA-approved package labeling.
|120 MME Limit for Single- and Multi-Agent Opioid Regimens
|Prior authorization will be required if a member’s opioid regimen exceeds 120 MME/day. This limit applies regardless of whether the member’s pain regimen consists of one or multiple opioids.
|High Dose Short-Acting Monotherapy
|Prior authorization required for short-acting and combination agents when dosage limits are exceeded and the short-acting agents are being used as monotherapy (i.e., no claim for a long-acting opioid agent within the last 30 days).
|Duplicate Long-Acting Opioids
|For any combination of long-acting opioids, if there is greater than two months of duplicate claims in a member’s claims history, the opioid will require prior authorization.
|Duplicate Short-Acting Opioids
|For any combination of short-acting opioids, powders, and combination products, if there is greater than two months of duplicate claims in a member’s claims history, then the opioid will require prior authorization.
|Concurrent Therapy with Opioid Dependence Agents
|Prior authorization is required if a member is stable on any buprenorphine product used for substance use disorder and is attempting to fill a long-acting opioid (for any length of time), a short-acting opioid for more than a 7-day supply, or short-acting opioid(s) for more than 7 days of therapy with the last 30 days.
“Stability” is defined as the following:
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