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. (Citation: DOWC Rule 16-6, 16-10(B) and Rule 17, Exhibit 9, pp. 100-112) Pinnacol implemented the new statutory limit on initial opioid prescriptions as enacted by SB 18-022 in 2018. (Citation: CRS 12-36-117.6)
Pinnacol Assurance implemented these changes to help address the epidemic of opioid misuse and abuse, as allowed by the November 2017 update to the Division of Workers’ Compensation (DOWC) Chronic Pain Disorder Medical Treatment Guideline and the newly enacted SB 18-022.
Following are specifics of these changes:
Per SB 18-022, 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. In addition, per the DOWC, new opioid prescriptions should be limited to no more than 50 morphine milligram equivalents (MME) per day. Citation: DOWC Rule 18-8(A)(3). As of 1/1/20, opioid/scheduled controlled substances (ex. Tramadol) that are prescribed for treatment longer than three days shall be provided through a pharmacy. Citation: DOWC Rule 18-6(C)(2)(e)
To make a prior authorization request after the initial 14 day supply, providers will need to address several informational items that are summarized on the Pinnacol website. For a limited time and in order to help providers transition to this new process, Pinnacol nurse advisers will attempt to contact the provider proactively to facilitate the provider’s prior authorization request. The provider should be responsive to these communications to justify the reasonableness and the medical necessity of prescribing opioids. Citation: DOWC Rule 16-10(B)
To avoid a potential interruption in treatment, prior authorization must be requested by the prescriber within 7 days of a patient requiring a refill. Citation: DOWC Rule 16-6(C) and 16-10.
Upon receipt of a prior authorization request, a nurse adviser may approve payment for additional, limited quantities of opioids. 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 new Pinnacol policy, please contact either: Tara McCormack, RN, BSN, CCM, at 303-361-4344 or firstname.lastname@example.org or Kathryn Scott, RN, BSN, CCM, at 303-361-4084 or email@example.com.