- Opioid Induced Constipation:
Age Requirement: >= 18
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Patient must have chronic use of opioids: No
Patient must not be using methadone: No
Supporting Documentation Requirements: Chart Notes
Failed or intolerant to increase in dietary fiber or conventional laxative therapy: Yes
- Step Therapy: Opioid Induced Constipation:
ST Generic and Brand
- unspecified ST criteria Step Therapy Exists in PA
- Prior Authorization: Opioid Induced Constipation:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- I. FDA Approved Indications: A. Treatment of opioid-induced constipation (OIC) in patients with advanced illness who are receiving palliative care, when response to laxative therapy has not been sufficient. B. Treatment of opioid-induced constipation in adult patients with chronic non-cancer pain. II. Health Net Approved Indications and Usage Guidelines: A. Failure or clinically significant adverse effects to TWO of the following: 1. Over the counter (OTC) laxatives (e.g., docusate, bisacodyl, polyethylene glycol); 2. Amitiza; 3. Movantik. AND B. Treatment of opioid-induced constipation in patients with advanced illness who are receiving palliative care, when response to laxative therapy has not been sufficient. OR C. Treatment of opioid-induced constipation in adult patients with chronic non-cancer pain. III. Coverage is Not Authorized For: A. Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature. B. Patients with known or suspected mechanical gastrointestinal obstruction.
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