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Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
DESCRIPTIONOpioid medications play an important role in the treatment of both acute and chronic pain. There are therapeutic equivalent generic alternatives to many of the newer brand name opioids. They vary in the dosage forms and delivery systems therefore providing treatment options for individual patient preference. Long-acting opioids, in particular, are indicated for the relief of moderate to severe pain in patients requiring continuous around the clock opioid treatment for an extended period of time and should not be used on an as-needed basis. Certain higher potency opioids are recommended to be used in opioid tolerant patients, and should be restricted to certain medical conditions. Patients considered opioid tolerant are those who are taking at least 60 mg morphine/day, at least 25 mcg transdermal fentanyl/hour, at least 30 mg of oxycodone daily, at least 8 mg oral hydromorphone daily or an equipotent dose of another opioid for a week or longer. Short-acting opioids with a shorter half-life are usually preferred for initial pain therapy or acute pain that’s self-limiting or lasting from a few days to a few weeks. There has not been sufficient evidence demonstrating a significant clinical difference among opioids in terms of efficacy at equivalent doses, neither has there been any evidence supporting the polypharmacy of long-acting opioids.
POLICYOxycontin, Opana ER, or Levo-Dromoran will be approved when at least one of the following are met:
1. The patient has a diagnosis of clinically significant cancer OR
2. The patient meets hospice criteria with the primary diagnosis of a malignancy OR
3. The patient has a diagnosis of chronic pain requiring a long acting opioid analgesic AND
4. The patient has a documented trial and failure at therapeutic maximum doses or intolerance to sustained release morphine sulfate AND
5. The patient has a documented trial and failure at therapeutic maximum doses or intolerance to fentanyl.
POLICY EXCEPTIONSOpioid pain medication prior authorization is not required for Federal Employee Program (FEP) and State Health Plan members.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
01/01/2014: New policy added.
08/03/2015: Code Reference section updated for ICD-10.
SOURCE(S)Oxycontin® Prescribing Information
Opana ER® Prescribing Information
Nucynta ER® Prescribing Information
Levo-Dromoran® Prescribing Information
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.