- Step Therapy Applies
- Prior Authorization: I. FDA Approved Indications: The management of breakthrough pain in cancer patients (>=16 years old) who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. II. Health Net Approved Indications and Usage Guidelines: A. Diagnosis of cancer; AND B. Member is on fentanyl transdermal patches; AND C. A treatment plan is required, including: 1. Diagnosis or conditions that are contributing to the pain; 2. Pain intensity (scales or ratings); 3. Functional status (physical and psychosocial); 4. Patient's goal of therapy (level of pain acceptable and/or functional status); 5. Current analgesic (opioid and adjuvant) regimen; 6. Current non-pharmacological treatment; 7. Opioid-related side effects; 8. Indications of medical misuse; 9. Action plan if analgesic failure occurs. III. Authorization Limit: Length of benefit.
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
- I. FDA Approved Indications: The management of breakthrough pain in cancer patients (>=16 years old) who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. II. Health Net Approved Indications and Usage Guidelines: A. Diagnosis of cancer; AND B. Member is on fentanyl transdermal patches; AND C. A treatment plan is required, including: 1. Diagnosis or conditions that are contributing to the pain; 2. Pain intensity (scales or ratings); 3. Functional status (physical and psychosocial); 4. Patient's goal of therapy (level of pain acceptable and/or functional status); 5. Current analgesic (opioid and adjuvant) regimen; 6. Current non-pharmacological treatment; 7. Opioid-related side effects; 8. Indications of medical misuse; 9. Action plan if analgesic failure occurs. III. Authorization Limit: Length of benefit.
|