Pinnacol requires prior authorization for reimbursement for new opioid prescriptions in excess of a 14-day supply. Separate and additional prior authorization may be required for opioids beyond a 30-day supply.
This policy was implemented to help address the epidemic of opioid misuse and abuse. The use of opioids may impact the ability to return to work. If workers are under the influence of opioids while they are at work, they are likely to be at increased risk for injury to themselves or others.
Prescribing Limits
- For patients receiving an initial opioid prescription in an acute situation, prescribers must limit the initial prescription of opioid narcotics to no more than a 7-day supply.
- The provider may exercise discretion to prescribe a second, additional 7-day supply after checking the Prescription Drug Monitoring Program database.
- Opioids and scheduled controlled substances, including benzodiazepines, must be provided through a pharmacy. Citation: DOWC Rule 18-6(C)(2)(e)
- New opioid prescriptions should be limited to no more than 50 morphine milligram equivalents (MME) per day.
- All opioids are monitored and Pinnacol medical case managers receive clinical alerts for all new opioid starts.
Prior Authorization
- To make a prior authorization request after the initial 14 day supply, providers will need to address several informational items summarized on the Pinnacol website. Providers must justify the reasonableness and the medical necessity of prescribing opioids. Citation: DOWC Rule 16- 7(C)
- To avoid a potential interruption in treatment, payers shall respond to prior authorization requests within 10 days from the receipt of the request from the prescriber. Citation: DOWC Rule 16-7(B)
- Upon receipt of the request, a medical case manager may approve payment for additional, limited quantities of opioids. The provider and injured worker are notified by phone and letter.
- Failure to request prior authorization and/or an independent expert review may result in denial of payment for additional opioids.
Pinnacol does not intend to direct the type or duration of medical treatment that may be prescribed. Prescribing providers must exercise independent medical judgment in these matters.
If you have questions about this Pinnacol policy, please contact: Tara McCormack, RN, BSN, CCM, at 303-361-4344 or tara.mccormack@pinnacol.com.
