Tennessee Pharmacists Association
TennCare

Changes to Prior Authorization Criteria for the PDL effective July 1, 2016

TennCare issued an updated provider notice yesterday to clarify some of the July 1 changes for opioids, outlined below. CLICK HERE to view the complete updated notice.

Effective July 1, 2016, prior authorization criteria for agents in the Short Acting Narcotics PDL class will be changed. This will ONLY apply to agents which are already subject to prior authorization (non-preferred agents and quantity limit overrides). Existing Prior Authorizations will be honored through the current expiration date. New requests for Prior Authorizations, effective 7/1/16 will include the following:

  • Must be prescribed by a provider with a Tennessee Medicaid Provider ID.
  • Pain agreement required for all PA required agents. For example agreement, please refer to the Opioid and Controlled Substance Agreement document located at: bit.ly/299agns.
  • Concomitant use of benzodiazepines and opioids will only be approved under the care of, or referral to, a mental health provider.
  • Prior Authorization approval duration: 3 months.

Effective July 1, 2016, prior authorization criteria for agents in the Long Acting Narcotics PDL class will be changed. This will ONLY apply to agents which are already subject to prior authorization (preferred agents requiring PA, non-preferred agents and quantity limit overrides). Existing Prior Authorizations will be honored through the current expiration date. New requests for Prior Authorizations, effective 7/1/16 will include the following:

  • Must be prescribed by a provider with a Tennessee Medicaid Provider ID.
  • Pain agreement required for all PA required agents. For example agreement, please refer to the Opioid and Controlled Substance Agreement document located at: bit.ly/299agns.
  • Concomitant use of benzodiazepines and opioids will only be approved under the care of, or referral to, a mental health provider.
  • Prior Authorization approval duration: 3 months.
  • Established opioid tolerance will be required before approval of opioids with REMS requirements. (See chart below.)
Opioids Requiring a Risk Evaluation and Mitigation Strategy  (REMS)
Avinza (morphine sulfate ER capsules) Kadian(morphine sulfate ER capsules)
Butrans (buprenorphine transdermal system) MS Contin (morphine sulfate CR tablets)
Dolophine (methadone hydrochloride tablets) Nucynta ER(tapentadol ER tablets)
Duragesic (fentanyl transdermal system) Opana ER (oxymorphone HCL ER tablets)
Embeda (morphine sulfate/naltrexone ER capsules) OxyContin (oxycodone HCL CR tablets)
Exalgo (hydromorphone hydrochloride ER tablets) Kadian(morphine sulfate ER capsules)