- A. Health Net Approved Indications and Usage Guidelines: 1. Chronic pain for which there is a documented, objective etiology. AND 2. A treatment plan is required, including: a.Diagnosis or conditions that are contributing to the pain; b.Pain intensity (scales or ratings); c.Functional status (physical and psychosocial); d.Patient's goal of therapy (level of pain acceptable and/or functional status); e.Current analgesic (opioid and adjuvant) regimen; f.Current non-pharmacological treatment; g.Opioid-related side effects; h.Indications of medical misuse; i.Action plan if analgesic failure occurs. AND 3. Failure or clinically significant adverse effects to two of the following: controlled-release morphine sulfate (MS Contin), morphine sulfate sustained-release beads (Kadian), transdermal fentanyl patches, extended release oxymorphone, extended-release morphine sulfate (Avinza), or Oxycontin; B. Coverage is Not Authorized For: 1. Acute or intermittent pain; 2. Immediate postsurgical pain; 3. Use in patients who require opioid analgesia for a short period of time or as needed pain relief. C. Authorization Limit: 1. Three months initially for non-malignant pain. Duration of authorization to be determined for up to one year. 2.Treatment plan may be required for continued authorization. 3. One year for cancer patients.
- Step Therapy: Step Therapy Exists in PA
- Prior Authorization: Pain Narcotic: Opioid:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy Exists in PA
- Pain Narcotic: Opioid:
Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Chronic Pain
Used for Cancer Patients: No
Around-The-Clock Analgesic Required: No
Morphine Equivalent Dose (MED) Limit: N/A
Morphine Equivalent Dose (MED) Required: No
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