Fentanyl Agents Clinical Edit Criteria
|
|
|
- Barnard Horton
- 5 years ago
- Views:
Transcription
1 Fentanyl Agents Clinical Edit Criteria Drug/Drug Class: Fentanyl Agents Superior HealthPlan follows the guidance of the Texas Vendor Drug Program (VDP) for all clinical edit criteria. Superior has adjusted the clinical criteria to ease the prior authorization process regarding this clinical edit. Changes to the original edit are noted in yellow highlight within this document. Fentora products have been removed from the edit and will be considered for coding at a later time. The original clinical edit can be referenced at the Texas Vendor Drug Program website located at Clinical Edit Information Included in this Document: Abstral (Fentanyl Sublingual Tablet) / Lazanda (Fentanyl Nasal Spray) / Subsys (Fentanyl Sublingual Spray Actiq (Oral Transmucosal Fentanyl) Duragesic (Transdermal Fentanyl) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria. Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules. Logic diagram: a visual depiction of the clinical edit criteria logic. Diagnosis codes or drugs in step logic: a list of diagnosis codes or drug information and additional step logic, claims and lookback period information. Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable. The supporting tables by VDP are so large that a cross reference has been provided to the original VDP edit as Superior implements the VDP s logic inside these tables. Clinical Edit References: clinical edit references as provided by the Texas Vendor Drug Program. Publication history: to track when the eased criteria was put into production and any updates since this time. Please note: All tables are provided by original Texas Vendor Drug Program Edit. SuperiorHealthPlan.com Page 1 of 13 SHP_
2 Drugs Requiring Prior Authorization Abstral / Lazanda / Subsys: Drugs Requiring Prior Authorization Label Name ABSTRAL 100MCG SUBLINGUAL TABLETS ABSTRAL 200MCG SUBLINGUAL TABLETS ABSTRAL 300MCG SUBLINGUAL TABLETS ABSTRAL 400MCG SUBLINGUAL TABLETS ABSTRAL 600MCG SUBLINGUAL TABLETS ABSTRAL 800MCG SUBLINGUAL TABLETS LAZANDA 100MCG NASAL SPRAY LAZANDA 300MCG NASAL SPRAY LAZANDA 400MCG NASAL SPRAY SUBSYS 1,200MCG SPRAY SUBSYS 1,600MCG SPRAY SUBSYS 100MCG SPRAY SUBSYS 200MCG SPRAY SUBSYS 400MCG SPRAY SUBSYS 600MCG SPRAY SUBSYS 800MCG SPRAY GCN
3 Superior HealthPlan Clinical Criteria Logic Abstral / Lazanda / Subsys: 1. Is the client 18 years of age? [ ] Yes (Go to #2) 2. Does the client have a diagnosis of malignancy in the last 730 days? [ ] Yes (Go to #4) [ ] No (Go to #3) 3. Does the client have a history of antineoplastic therapy in the last 365 days? [ ] Yes (Go to #4) 4. Does the client have a claim for a long-acting opioid analgesic in the last 30 days? [ ] Yes (Go to #5) 5. Does the patient have a claim for an MAOI or CYP3A4 inhibitor in the last 30 days? [ ] Yes (Deny) [ ] No (Go to #6) 6. Is the total daily dose less than or equal to ( ) 3200mcg? [ ] Yes (Approve 365)
4 Superior HealthPlan Clinical Edit Logic Diagram Abstral / Lazanda / Subsys: Deny request
5 Drugs Requiring Prior Authorization Actiq (Transmucosal Fentanyl): Drugs Requiring Prior Authorization Label Name ACTIQ 1,200 MCG LOZENGE ACTIQ 1,600 MCG LOZENGE ACTIQ 200 MCG LOZENGE ACTIQ 400 MCG LOZENGE ACTIQ 600 MCG LOZENGE ACTIQ 800 MCG LOZENGE FENTANYL CIT OTFC 1,200 MCG FENTANYL CIT OTFC 1,600 MCG FENTANYL CITRATE OTFC 200 MCG FENTANYL CITRATE OTFC 400 MCG FENTANYL CITRATE OTFC 600 MCG FENTANYL CITRATE OTFC 800 MCG GCN
6 Superior HealthPlan Clinical Criteria Logic Actiq (Transmucosal Fentanyl) 1. Is the client less than (<) 16 years of age? [ ] Yes (Deny) [ ] No (Go to #2) 2. Does the client have a diagnosis of cancer or fibrotic lung disease in the last 730 days? [ ] Yes (Go to #5) [ ] No (Go to #3) 3. Does the client have a history of antineoplastic therapy in the last 365 days? [ ] Yes (Go to #5) [ ] No (Go to #4) 4. Does the client have a diagnosis of CNMP in the last 365 days? [ ] Yes (Go to #5) 5. Does the client have less than or equal to ( ) 7 days of opioid therapy in the last 30 days? [ ] Yes (Deny) [ ] No (Go to #6) 6. Does the client have a claim for an MAOI or a strong/moderate CYP3A4 inhibitor in the last 30 days? [ ] Yes (Deny) [ ] No (Go to #7) 7. Is the request for transmucosal fentanyl 200mcg? [ ] Yes (Go to #10) [ ] No (Go to #8) 8. Is the request for transmucosal fentanyl greater than or equal to ( ) 400mcg? [ ] Yes (Go to #9) 9. Does the client have a history of transmucosal fentanyl therapy in the last 30 days with the dose greater than or equal to ( ) 200mcg? [ ] Yes (Go to #10) 10.Is the request for less than or equal to ( ) 4 units per day? [ ] Yes (Approve 365 days)
7 Superior HealthPlan Clinical Edit Logic Diagram Actiq (Transmucosal Fentanyl): Deny request
8 Drugs Requiring Prior Authorization Duragesic (Transdermal Fentanyl): Drugs Requiring Prior Authorization Label Name DURAGESIC 100 MCG/HR PATCH DURAGESIC 12 MCG/HR PATCH DURAGESIC 25 MCG/HR PATCH DURAGESIC 50 MCG/HR PATCH DURAGESIC 75 MCG/HR PATCH FENTANYL 100 MCG/HR PATCH FENTANYL 12 MCG/HR PATCH FENTANYL 25 MCG/HR PATCH FENTANYL 37.5 MCG/HR PATCH FENTANYL 50 MCG/HR PATCH FENTANYL 62.5 MCG/HR PATCH FENTANYL 75 MCG/HR PATCH FENTANYL 87.5 MCG/HR PATCH GCN
9 Superior HealthPlan Clinical Criteria Logic Duragesic (Transdermal Fentanyl): 1. Does the client have a diagnosis of cancer or fibrotic lung disease in the last 730 days? [ ] Yes (Go to #6) [ ] No (Go to #2) 2. Does the client have a history of an antineoplastic agent in the last 365 days? [ ] Yes (Go to #6) [ ] No (Go to #3) 3. Does the client have less than or equal to ( ) 7 days of opioid therapy in the last 30 days? [ ] Yes (Go to #4) [ ] No (Go to #6) 4. Does the client have a diagnosis of chronic non-malignant pain in the last 365 days? [ ] Yes (Go to #6) [ ] No (Go to #5) 5. Does the client have a history of an inferring CNMP non-opioid analgesic for less than or equal to ( ) 60 days out of the last 90 days? [ ] Yes (Deny) [ ] No (Go to #6) 6. Is the dose less than or equal to ( ) 25ug per hour? [ ] Yes (Go to #8) [ ] No (Go to #7) 7. Does the client have less than or equal to ( ) 14 days of opioid therapy in the last 30 days? [ ] Yes (Deny) [ ] No (Go to #8) 8. Is the dose less than or equal to ( ) 600ug per hour? [ ] Yes (Approve 365 days)
10 Superior HealthPlan Clinical Edit Logic Duragesic (Transdermal Fentanyl):
11 Clinical Criteria Supporting Tables Fentanyl Agents: Due to the size of the supporting tables provided by Texas Vendor Drug Program please reference for all supporting table documentation.
12 Clinical Criteria References: 1. Clinical Pharmacology [online database]. Tampa, FL: Elsevier/Gold Standard, Inc.; Available at Accessed on August 30, Micromedex [online database]. Available at Accessed on August 30, ICD-9-CM Diagnosis Codes Available at Accessed on April 3, ICD-10-CM Diagnosis Codes Available at Accessed on April 3, American Medical Association data files ICD-9-CM Diagnosis Codes. Available at 6. American Medical Association data files ICD-10-CM Diagnosis Codes. Available at 7. Abstral Prescribing Information. Sentynl Therapeutics, Inc. Solana Beach, CA. November Lazanda Prescribing Information. Newark, CA. Depomed, Inc. March Subsys Prescribing Information. Chandler, AZ. Insys Therapeutics, Inc. December Actiq Prescribing Information. Frazer, PA. Cephalon, Inc. December Duragesic Prescribing Information. Titusville, NJ. Janssen Pharmaceuticals, Inc. April Fentora Prescribing Information. North Wales, PA. Teva Pharmaceuticals USA. February Xtampza Prescribing Information. Cincinnati, OH. Collegium Pharmaceutical, Inc. April 2016.
13 Publication History: Publication 11/5/18 Notes Criteria created and cross referenced to VDP criteria.
Texas Prior Authorization Program Clinical Criteria
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
NATL. II. Health Net Approved Indications and Usage Guidelines: Diagnosis of cancer AND. Member is on fentanyl transdermal patches AND
Coverage of drugs is first determined by the member s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document I. FDA Approved Indications: The management of breakthrough
Flexeril/Amrix (Cyclobenzaprine) Clinical Edit Criteria
Flexeril/Amrix (Cyclobenzaprine) Clinical Edit Criteria Drug/Drug Class: Flexeril/Amrix (Cyclobenzaprine) Superior HealthPlan follows the guidance of the Texas Vendor Drug Program (VDP) for all clinical
Transmucosal Immediate Release Fentanyl (TIRF) Prior Authorization, (Through Generic), and Quantity Limit Program Summary
Transmucosal Immediate Release Fentanyl (TIRF) Prior Authorization, (Through Generic), and Quantity Limit Program Summary FDA APPROVED INDICATIONS DOSAGE 1-5 Drug Indication Dosage Abstral (fentanyl sublingual
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Transmucosal Immediate Release Fentanyl Products Reference Number: CP.CPA.211 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Transmucosal Immediate Release Fentanyl Products Reference Number: CP.HNMC.211 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document DPP-4 Inhibitor Criteria A: Alogliptin 6.25mg, Januvia 25mg, Nesina 6.25mg, Onglyza
Short-Acting Fentanyl
Short-Acting Fentanyl Policy Number: 5.01.528 Last Review: 08/2018 Origination: 9/2007 Next Review: 08/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for oral short-acting
Xyrem (Sodium Oxybate)
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
Prior Authorization Neurontin (gabapentin) 2016
Drugs Requiring Prior Authorization Label Name GCN GABAPENTIN 100 MG CAPSULE 00780 GABAPENTIN 300 MG CAPSULE 00781 GABAPENTIN 400 MG CAPSULE 00782 GABAPENTIN 250 MG/5 ML SOLN 13235 GABAPENTIN 600 MG TABLET
Diclofenac 3% Gel, Diclofenac 1.5% and 2% Topical Solution
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class, Diclofenac 1.5% and 2% Topical Solution This criteria was recommended for review by an MCO to ensure appropriate and safe utilization
Committee Approval Date: September 12, 2014 Next Review Date: September 2015
Medication Policy Manual Topic: fentanyl-containing medications: - Actiq, fentanyl citrate oral transmucosal lozenges - Abstral fentanyl sublingual tablets - Fentora, fentanyl buccal tablet - fentanyl
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Provigil (Modafinil) Drugs requiring prior authorization: the list of drugs
Cigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Transmucosal Fentanyl Effective Date... 4/15/2018 Next Review Date... 4/15/2019 Coverage Policy Number... 1018 Table of Contents Coverage Policy... 1 General
Duragesic patch. Duragesic patch (fentanyl patch) Description
1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.31 Subject: Duragesic patch Page: 1 of 6 Last Review Date: March 18, 2016 Duragesic patch Description Duragesic patch (fentanyl
Lidoderm (Lidocaine) Patch
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
Texas Prior Authorization Program Clinical Criteria
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Information Included in this Document Xifaxan 200mg Drugs requiring prior authorization: the list of drugs requiring prior authorization
Sitagliptin (Januvia)
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document 25mg Drugs requiring prior authorization: the list of drugs requiring prior
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Xifaxan 200mg Drugs requiring prior authorization: the list of drugs requiring
Prior Authorization Flexeril/Amrix (cyclobenzaprine) 2017
Drugs Requiring Prior Authorization Label Name GCN AMRIX ER 15 MG CAPSULE 97959 AMRIX ER 30 MG CAPSULE 97960 CYCLOBENZAPRINE 10 MG TABLET 18020 CYCLOBENZAPRINE 5 MG TABLET 12805 CYCLOBENZAPRINE 7.5 MG
Amitiza (Lubiprostone)
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Combination Agents
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Combination Agents This criteria was recommended for review by an MCO to ensure appropriate
Texas Prior Authorization Program Clinical Criteria. This criteria was recommended for review by an MCO to ensure appropriate and safe utilization.
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class This criteria was recommended for review by an MCO to ensure appropriate and safe utilization. Clinical Information Included in this
1. Developed: February Revised: December 2017; December 2015; March 2014; May 2012; July 2010; July 2007; January 2006.
Texas Vendor Drug Program Drug Use Criteria: Fentanyl (inhalation, oral and transdermal) Publication History 1. Developed: February 2003 2. Revised: December 2017; December 2015; March 2014; May 2012;
Pharmacy Medical Necessity Guidelines: Opioid Analgesics
Pharmacy Medical Necessity Guidelines: Effective: January 1, 2019 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED) Benefit
Limitations of use: Subsys may be dispensed only to patients enrolled in the TIRF REMS Access program (1).
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.21 Subject: Subsys Page: 1 of 5 Last Review Date March 17, 2017 Subsys Description Subsys (fentanyl
Glucagon-Like Peptide (GLP-1) Receptor Agonists Clinical Edit Criteria
Glucagon-Like Peptide (GLP-1) Receptor Agonists Clinical Edit Criteria Drug/Drug Class: Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists Superior HealthPlan follows the guidance of the Texas Vendor Drug
Texas Prior Authorization Program Clinical Criteria
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Aldurazyme Adagen Carbaglu Ceprotin Elaprase Fabrazyme Lumizyme Naglazyme Orfandin Ravicti Vimizim Note: Click the hyperlink to navigate
Agents for the Treatment of Hepatitis C
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
Education Program for Prescribers and Pharmacists
Transmucosal Immediate Release Fentanyl (TIRF) Products Risk Evaluation and Mitigation Strategy (REMS) Education Program for Prescribers and Pharmacists Products Covered Under this Program Abstral (fentanyl)
ORAL TRANSMUCOSAL AND NASAL FENTANYL UTILIZATION MANAGEMENT CRITERIA
ORAL TRANSMUCOSAL AND NASAL FENTANYL UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: BRAND (generic) NAMES: Fentanyl by oral transmucosal and nasal delivery Actiq (fentanyl citrate) lozenge on a handle 200,
Nucynta IR/ Nucynta ER (tapentadol immediate-release and extendedrelease)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Nucynta Page: 1 of 7 Last Review Date: March 18, 2016 Nucynta Description Nucynta IR/ Nucynta
Methylnaltrexone Bromide (Relistor)
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Thiazolidinediones Clinical Edit Information Included in this Document Thiazolidinediones Drugs requiring prior authorization: the
Prior Authorization Opioid Overutilization 2017
Drugs Requiring Prior Authorization Label Name ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE CAPSULE ACETAMINOPHEN/CODEINE SOLUTION ACETAMINOPHEN/CODEINE TABLET ASCOMP/CODEINE CAPSULE BUTALBITAL/CAFFEINE/ACETAMINOPHEN/CODEINE
FENTANYL CITRATE TRANSMUCOSAL UTILIZATION MANAGEMENT CRITERIA
FENTANYL CITRATE TRANSMUCOSAL UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: BRAND (generic) NAMES: HICL = H3AT Fentanyl citrate transmucosal Actiq (fentanyl citrate) lozenge on a handle 200, 400, 600, 800,
Oxymorphone (Opana ) is indicated for the relief of moderate-to-severe acute pain where the use of an opioid is appropriate.
Page 1 of 7 Policies Repository Policy Title Policy Number Schedule II Prior Authorization FS.CLIN.16 Application of Pharmacy Policy is determined by benefits and contracts. Benefits may vary based on
MEDICARE Program Policies & Procedures POLICY NUMBER: Medicare D-111
POLICY: Medicare Part D Formulary-Level Cumulative Opioid and Opioid/Buprenorphine POS Edits MEDICARE Program Policies & Procedures POLICY NUMBER: Medicare D-111 Policy for contracts H3351, S3521 and H3335
Texas Prior Authorization Program Clinical Criteria. Allergen Extracts
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Information Included in this Document Oralair (Mixed Grass Pollens Allergen Extract)) Drugs requiring prior authorization: the
Embeda. Embeda (morphine sulfate and naltrexone hydrochloride) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.39 Subject: Embeda Page: 1 of 6 Last Review Date: March 18, 2016 Embeda Description Embeda (morphine
AETNA BETTER HEALTH Prior Authorization guideline for Narcotic Analgesic Utilization
AETNA BETTER HEALTH Prior Authorization guideline for Narcotic Analgesic Utilization Policy applies to all formulary and non-formulary schedules II V opioid narcotics, including tramadol and codeine, as
Demerol (meperidine oral tablet, oral solution), Meperitab (oral tablet)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subsection: Analgesics and Opioids Original Policy Date: May 8, 2015 Subject: Meperidine Page: 1 of 5 Last
Hypoglycemics, Lantus Insulin
Texas Prior Authorization Program PDL Edit Criteria Drug/Drug Class Hypoglycemics, Lantus Insulin Information Included in this Document Hypoglycemics, Lantus Insulin Drugs requiring prior authorization:
Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria
Drug/Drug Class Antipsychotics Clinical Criteria Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior
Injectable Agents for the Treatment of Pulmonary Arterial Hypertension (PAH)
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Injectable Agents for the Treatment of Pulmonary Arterial Hypertension (PAH) Clinical Edit Information Included in this Document
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Aldara 5% Cream Drugs requiring prior authorization: the list of drugs requiring
Victoza (Liraglutide) Solution for Injection
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Reference Number: CP.CPA.259 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory
Capital BlueCross Open/Closed Formulary Update (1 st Quarter 2017)
Capital BlueCross Open/Closed Formulary Update (1 st Quarter 2017) The Capital BlueCross formulary is a reference list of prescription drugs that contains a wide range of generic and brand drugs that have
Texas Prior Authorization Program Clinical Edit Criteria. H.P. Acthar
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
Opiate/Benzodiazepine/Muscle Relaxant Combinations
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Opiate/Benzodiazepine/Muscle Relaxant Combinations Clinical Edit Information Included in this Document Drugs requiring prior authorization:
Proposed Changes to Existing Measure for HEDIS : Use of Opioids at High Dosage (UOD)
Proposed Changes to Existing Measure for HEDIS 1 2020: Use of Opioids at High Dosage (UOD) NCQA seeks comments on proposed revisions to the Use of Opioids at High Dosage HEDIS measure. The current measure
APPROVED PA CRITERIA. Initial Approval: January 10, 2018 Revised Dates: April 11, 2018 CRITERIA FOR PRIOR AUTHORIZATION
Initial Approval: January 10, 2018 Revised Dates: April 11, 2018 CRITERIA FOR PRIOR AUTHORIZATION PROVIDER GROUP Pharmacy Opioid Products Indicated for Pain Management MANUAL GUIDELINES All dosage forms
New Medicines Committee Briefing November 2011 Abstral (sublingual fentanyl citrate tablet) for the management of breakthrough cancer pain
New Medicines Committee Briefing November 2011 Abstral (sublingual fentanyl citrate tablet) for the management of breakthrough cancer pain Abstral is to be reviewed for use within: Primary Care Secondary
Cigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Controlled Substance Analgesic and Narcotic Antagonist Quantity Limitations Table of Contents Coverage Policy... 1 General Background... 6 Coding/Billing
Dose titration of sublingual fentanyl, in relation to transdermal fentanyl dosing in cancer patients
74 Dose titration of sublingual fentanyl, in relation to transdermal fentanyl dosing in cancer patients Amaniti E MD, PhD, Zaralidou A MD, Maidatsi P MD, PhD, Mitos G MD, Thoma G MD, Vasilakos D MD, PhD.
Morphine Sulfate Hydromorphone Oxymorphone
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.02.33 Subject: Morphine Drug Class Page: 1 of 8 Last Review Date: June 19, 2015 Morphine Sulfate Hydromorphone
Suffolk PCT Drug & Therapeutics Committee New Medicine Report
Suffolk PCT Drug & Therapeutics Committee New Medicine Report This drug has been reviewed because it is a product that may be prescribed in primary care. Medicine Fentanyl citrate oral and intranasal preparations
NOVIDADES NO TRATAMENTO COM OPIOIDES. Novelties in therapeutic with opioids. V Congresso National de Cuidados Palliativos Marco 2010, Lisboa
NOVIDADES NO TRATAMENTO COM OPIOIDES Novelties in therapeutic with opioids V Congresso National de Cuidados Palliativos 11 12 Marco 2010, Lisboa Friedemann Nauck Department Palliative Medicine Center Anesthesiology,
Immediate release fentanyl (DROP-List)
Bulletin 132 April 2016 Community Interest Company Immediate release fentanyl (DROP-List) This is one of a number of bulletins providing further information on medicines contained in the PrescQIPP DROP-List
1/21/14. Cancer Related Pain: Case-Based Pharmacology. Conflicts of Interest. Learning Objective
Cancer Related Pain: Case-Based Pharmacology Jeannine M. Brant, PhD, APRN, AOCN Oncology Clinical Nurse Specialist Nurse Scientist Billings Clinic Conflicts of Interest Jeannine Brant has served on the
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
Methadone. Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.41 Subject: Methadone Page: 1 of 8 Last Review Date: March 18, 2016 Methadone Description Dolophine
: Opioid Quantity Limits
March 7, 2017 2017-09: Opioid Quantity Limits The Louisiana Department of Health (LDH), in conjunction with the Louisiana Medicaid Drug Utilization Review (DUR) Board, has revised quantity limits for selected
QUANTITY LIMIT AND POST LIMIT PRIOR AUTHORIZATION CRITERIA
DRUG CLASS QUANTITY LIMIT AND POST LIMIT PRIOR AUTHORIZATION CRITERIA EXTENDED-RELEASE OPIOID ANALGESICS BRAND NAME (generic) ARYMO ER (morphine sulfate extended-release tablets) AVINZA (morphine extended-release
General Providers. Tamper-Resistant Prescription Requirements
September 2008 Provider Bulletin Number 8138 General Providers Tamper-Resistant Prescription Requirements Effective with processing dates on and after October 1, 2008, written prescriptions for Kansas
Flexeril/Amrix (Cyclobenzaprine)
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
DURATION LIMIT WITH QUANTITY LIMIT AND POST LIMIT PRIOR AUTHORIZATION CRITERIA IMMEDIATE-RELEASE OPIOID ANALGESICS (BRAND AND GENERIC)*
Carelirst. +.V Family of health care plans cvs caremarktm DURATION LIMIT WITH QUANTITY LIMIT AND POST LIMIT PRIOR AUTHORIZATION CRITERIA DRUG CLASS generic name, dosage form IMMEDIATE-RELEASE OPIOID ANALGESICS
Pharmacy Management Drug Policy
SUBJECT: Opioid Management Health and Safety Program POLICY NUMBER: PHARMACY-34 EFFECTIVE DATE: 6/2007 LAST REVIEW DATE: 07/01/2018 If the member s subscriber contract excludes coverage for a specific
Agents for Cystic Fibrosis
Texas Prior Authorization Program Clinical Edit Criteria Clinical Edit Information Included in this Document Kalydeco (Ivacaftor) Drugs requiring prior authorization: the list of drugs requiring prior
Breakthrough Cancer Pain (BTCP) 25 Years of Study: Key Insights
Breakthrough Cancer Pain (BTCP) 25 Years of Study: Key Insights Steven Wong, MD Assistant Professor of Medicine, Department of Medicine, Division of Hematology/Oncology, UCLA David Geffen School of Medicine
Scottish Medicines Consortium
Scottish Medicines Consortium fentanyl 50 micrograms / dose, 100 micrograms/dose, 200 micrograms / dose nasal spray (Instanyl ) No. (579/09) Nycomed UK Ltd 09 October 2009 The Scottish Medicines Consortium
Public Assessment Report. Scientific discussion. Abstral, sublingual tablet 50, 100, 200, 300, 400, 600 and 800 μg. (Fentanyl citrate)
Public Assessment Report Scientific discussion Abstral, sublingual tablet 50, 100, 200, 300, 400, 600 and 800 μg (Fentanyl citrate) SE/H/575/01-07/DC This module reflects the scientific discussion for
Long-Acting Opioid Analgesics
Market DC Long-Acting Opioid Analgesics Override(s) Prior Authorization Step Therapy Quantity Limit Approval Duration Initial request: 3 months Maintenance Therapy: Additional prior authorization required
Equianalgesic Dosing of Opioids for Pain Management
PL Detail-Document #300405 This PL Detail-Document accompanies the related article published in PHARMACIST S LETTER / PRESCRIBER S LETTER April 2014 Equianalgesic Dosing of Opioids for Pain Management
Long-Acting Opioid Analgesics
Market DC Long-Acting Opioid Analgesics Override(s) Prior Authorization Step Therapy Quantity Limit Approval Duration Initial request: 3 months Maintenance Therapy: Additional prior authorization required
Cough/Cold Medications
Texas Prior Authorization Program Clinical Edit Criteria Cough/Cold Medications NOTE: Claims for cough and cold products containing acetaminophen, ibuprofen, or hydrocodone are not covered by Texas Medicaid
Opioid Conversions Mixture of Science and Art
Opioid Conversions Mixture of Science and Art Matthew J. Pingree, MD Assistant Professor Division of Pain Medicine Physical Medicine and Rehabilitation and Anesthesiology Mayo Clinic, Rochester Pingree.Matthew@Mayo.edu
UnitedHealthcare Pharmacy Clinical Pharmacy Programs
UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2018 P 3053-9 Program Step Therapy Long Acting Opioids Medication Includes both brand and generic versions of the listed products unless
Prior Authorization Guideline
Guideline GL-35952 Opioid Quantity Limit Overrides Formulary OptumRx Formulary Note: Approval Date 7/10/2017 Revision Date 7/10/2017 Technician Note: P&T Approval Date: 2/16/2010; P&T Revision Date: 7/12/2011
IT S NOT JUST HEROIN ANYMORE: EVOLVING ROLE OF FENTANYL IN DRUG OVERDOSE. By Phil Walls, RPh and Michael Nguyen, PharmD
IT S NOT JUST HEROIN ANYMORE: EVOLVING ROLE OF FENTANYL IN DRUG OVERDOSE By Phil Walls, RPh and Michael Nguyen, PharmD IT S NOT JUST HEROIN ANYMORE: EVOLVING ROLE OF FENTANYL IN DRUG OVERDOSE mymatrixx
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document - Oral Drugs requiring prior authorization: the list of drugs requiring prior
Levorphanol. Levorphanol Tartrate. Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.59 Subject: Levorphanol Page: 1 of 8 Last Review Date: March 16, 2018 Levorphanol Description Levorphanol
Conversion chart from fentanyl to opana er
Conversion chart from fentanyl to opana er (e.g., Nucynta). Both opioid products involved in conversion are one of the following: morphine, oxycodone, oxymorphone, hydromorphone (not extended- release),
Pharmacological Pain Management, the Evolving Role of Opioids, and Improving Education of Health Care Providers
Pharmacological Pain Management, the Evolving Role of Opioids, and Improving Education of Health Care Providers James P. Rathmell, M.D. Chair, Department of Anesthesiology, Perioperative and Pain Medicine
STEP THERAPY WITH QUANTITY LIMIT AND POST LIMIT PRIOR AUTHORIZATION CRITERIA. AVINZA (morphine extended-release capsules)
Carelirst. +.V Family of health care plans cvs caremarktm STEP THERAPY WITH QUANTITY LIMIT AND POST LIMIT PRIOR AUTHORIZATION CRITERIA DRUG CLASS EXTENDED-RELEASE OPIOID ANALGESICS BRAND NAME* (generic)
Session VI. Presenter Disclosure Information. Learning Objectives for Session VI. Prescribing Information. Prescribers Must Be Knowledgeable
SAFE Opioid Prescribing Strategies. Assessment. Fundamentals. Education 4 6pm SPEAKERS Charles Argoff, MD, FABPM Michael Brennan, MD, FACP, FASAM Jeffrey Gudin, MD Presenter Disclosure Information The
Drug Use Evaluation: Short Acting Opioids (SAO)
Drug Use Evaluation: Short Acting Opioids (SAO) Summary Short acting opioid analgesics are one of the most prescribed (top 10) and highest cost (top 20) medication classes for the Oregon Fee For Service
PAIN CONTROL IN THE PATIENT WITH ACUTE/CHRONIC PAIN JAY E. OLSSON,DO AOBPMR DCAQPM ABPMR ABPM
PAIN CONTROL IN THE PATIENT WITH ACUTE/CHRONIC PAIN JAY E. OLSSON,DO AOBPMR DCAQPM ABPMR ABPM Disclaimers Speaker Bureau Avanir Pharmaceuticals Nuedexta Pfizer Inc. Embeda Lyrica FOCUS Pharmacologic interventions
NDA MF REMS ASSESSMENT ACKNOWLEDGMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration Silver Spring MD 20993 REMS ASSESSMENT ACKNOWLEDGMENT Insys Development Co. c/o Insys Therapeutics, Inc. 1333 South Spectrum Blvd.,
Current Concepts of Phenylpiperidine Derivatives Use in the Treatment of Acute and Chronic Pain
Pain Physician 2017; 20:SE23-SE31 ISSN 2150-1149 Review Current Concepts of Phenylpiperidine Derivatives Use in the Treatment of Acute and Chronic Pain Nidal Elbaridi, MD 1, Alan David Kaye, MD, PhD 2,
EXTENDED RELEASE OPIOID DRUGS
RATIONALE FOR INCLUSION IN PA PROGRAM Background Hydrocodone (Hysingla ER, Vantrela ER, Zohydro ER), hydromorphone (Exalgo), morphine sulfate (Arymo ER, Avinza, Embeda, Kadian, MorphaBond, MS Contin),
London New Drugs Group APC/DTC Briefing Document
Page 1 London New Drugs Group APC/DTC Briefing Document Fentanyl preparations for breakthrough cancer pain Contents Summary 1 Issues for consideration 3 Background 3 Doses 4 Other treatments 4 Patients
Duragesic patch. Duragesic patch (fentanyl patch) Description
1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.31 Subject: Duragesic patch Page: 1 of 9 Last Review Date: September 15, 2017 Duragesic patch Description Duragesic patch (fentanyl
Duragesic patch. Duragesic patch (fentanyl patch) Description
1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.31 Section: Prescription Drugs Effective Date: April1, 2017 Subject: Duragesic patch Page: 1 of 10 Last Review Date: March
Bree Collaborative AMDG Opioid Prescribing Guidelines Workgroup. Opioid Prescribing Metrics - DRAFT
Bree Collaborative AMDG Opioid Prescribing Guidelines Workgroup Opioid Prescribing Metrics - DRAFT Definitions: Days Supply: The total of all opioid prescriptions dispensed during the calendar quarter
The original MED criteria can be referenced at the Texas Vendor Drug Program website located at
Morphine Equivalent Dosing (MED) Clinical Edit Criteria Drug/Drug Class Morphine Equivalent Dosing (MED) Superior HealthPlan follows the guidance of the Texas Vendor Drug Program (VDP) for all clinical