Medicaid Changing Prior Authorization Criteria for Certain Opioid Prescriptions
By David Doolittle


Beginning Sept. 1, Texas Medicaid will implement updated clinical prior authorization criteria for opioid prescriptions for certain Medicaid fee-for-service and managed care patients. 

The new policy is part of state efforts to help curb opioid addiction and diversion of unused medications, the Texas Health and Human Services Commission’s Vendor Drug Program (VDP) said. 

The new Opioid Policy Criteria – formerly known as the Morphine Milligram Equivalent [MME] criteria – will apply to patients who are “opioid naïve - people who have taken an opioid for less than 7 days within the previous 60-day period,” VDP said.   

Specifically, under the criteria, Texas Medicaid must require a one-time authorization for: 

  • An opioid prescription that exceeds a 10-day supply;
  • A prescription for a long-acting opioid formulation; and
  • A claim in which the total daily dose of opioids exceeds 90 MME. 

For members who no longer meet the definition of opioid naïve, an authorization will be required if the total daily dose of opioids exceeds 90 MME,” VDP said. “If approved, the authorization is for a six-month duration.” 

The updated criteria excludes patients diagnosed with cancer or sickle cell disease, or those receiving hospice or palliative care, VDP said.   

For more information, tips, and resources, check out the Texas Medical Association Opioid Resource Center.

Last Updated On

August 28, 2020

Originally Published On

August 28, 2020

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