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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.
Previous use of samples or vouchers/coupons will not be considered for authorization.
Oxycontin, Opana ER, or Levo-Dromoran will be approved when at least one of the following are met:
POLICY EXCEPTIONSOpioid pain medication prior authorization is not required for Federal Employee Program (FEP) and State Health Plan members.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
01/01/2014: New policy added.
08/03/2015: Code Reference section updated for ICD-10.
10/27/2015: Policy section updated to state: Previous use of samples or vouchers/coupons will not be considered for authorization.
02/02/2016: Approved by Pharmacy & Therapeutics (P&T) Committee. Investigative definition updated in policy guidelines section.
05/31/2016: Policy number L.5.01.459 added.
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.
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