Summary
New criteria and limits have been added for Tapentadol ER formulary coverage, and a 7-day duration limit with MME (Morphine Milligram Equivalent) limits has been implemented for immediate-release opioids in acute pain treatment. These changes affect the Metallic formulary tier and update opioid prescribing guidelines.
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What to do
Action · 4 steps
01Before October 1, 2026: Billing team must update prior authorization workflows for Tapentadol ER prescriptions to include new criteria requirements.
02Providers must be trained on the 7-day limit for immediate-release opioids in acute pain cases and MME calculation requirements.
03Update EMR templates to include MME tracking and duration limits for opioid prescriptions.
04Claims may be denied if new criteria and limits are not followed.
Original notice
Drug Policy Criteria Change
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