Opioid Analgesics PA Request Provider Checklist

Transcription

1 WVP Health Authrity Updated Opiid Analgesics PA Request Prvider Checklist *** If pssible, please include the fllwing infrmatin with PA requests fr piid analgesics. Including the requested infrmatin des nt guarantee PA apprval but will decrease PA prcessing time.*** All PA Requests fr Opiids: Is the medicatin being used fr the treatment f pain assciated with terminal illness r cancer? Is the medicatin being used fr the treatment f pain assciated with an acute injury r surgery? Is there an established pain treatment agreement and material risk ntice between patient and prvider? Has patient tried and failed nn-piid treatment alternatives? Des the patient have a histry f a suicide attempt? Requests Exceeding a 120 mg Mrphine Equivalent Dse (MED) per Day Has patient tried and failed treatment ptins under 120 mg MED per day? Has patient been evaluated by a pain management specialist r has prvider had a cnsultatin with a pain management specialist? Requests fr Cntinuatin f Therapy and Requests fr Over 90 Days f Treatment per Year Has patient been adherent t the established pain treatment agreement? Is there dcumentatin that the requested medicatin has demnstrated imprvement in patient s functin and pain status? Requests fr Nn-Frmulary Opiid Analgesics Has patient tried and failed frmulary ptins, r is there a reasn why frmulary ptins are cntraindicated? Requests fr Methadne Has patient tried and failed frmulary shrt-acting piid treatment alternatives? Has patient tried and failed frmulary lng-acting piid treatment alternative mrphine sulfate ER tablets? Requests fr Fentanyl Transdermal Patches Is the patient piid-tlerant? Is the medicatin being used fr the treatment f chrnic pain severe enugh t require daily, arund-theclck, lng-term piid treatment fr which alternative treatments are inadequate? Page 1 f 10

2 WVP Health Authrity Updated APPENDICES Table f 120 mg Mrphine Equivalent Dses (MED) OPIOID Cdeine Fentanyl Transdermal Patches Hydrcdne Hydrmrphne Methadne Oxycdne Oxymrphne DOSE THRESHOLD 800 mg per day 50 mcg/hr patches 120 mg per day 30 mg per day 40 mg per day 80 mg per day 40 mg per day Nn-Opiid Frmulary Treatment Alternatives Antidepressants (DMAP benefit): Amitriptyline, Nrtriptyline, Dulxetine, Venlafaxine Anticnvulsants: Gabapentin capsules, Carbamazepine Muscle Relaxants: Baclfen, Cyclbenzaprine, Methcarbaml, Tizanidine tablets NSAIDs: Aspirin, Celebrex (PA required), Diclfenac, Diclfenac/Misprstl, Etdlac, Ibuprfen, Indmethacin, Melxicam, Nabumetne (PA required), Naprxen, Salsalate, Sulindac. Nn-Opiid Analgesics: Acetaminphen Pain Treatment Agreements Pain treatment agreements shuld include plans fr randm UAs, randm pill cunts, prvider review f the prescriptin drug mnitring prgram (PDMP), patient use f a single pharmacy, a material risk ntice (MRN), and patient abstinence frm illegal drug use, marijuana use, and alchl abuse. Terminatin f Authrizatins WVCH reserves the right t revke previusly apprved authrizatins fr the fllwing: UA that is psitive fr illegal drugs, benzdiazepines, cntrlled substances that have nt been prescribed t member, r marijuana. UA that is negative fr prescribed medicatin despite regular fill histry, refusal f UDS, r failure t perfrm UDS. High risk behavir: Multiple narctics frm multiple prescribers frm multiple pharmacies, multiple verrides fr lst/stlen cntrlled substances, evidence f medicatin diversin. Nn-Funded Cnditins Requests fr patients with a histry f chrnic piid use with n dcumentatin f an OHP funded cnditin may be apprved as amended t allw fr dse tapering (apprval f up t 60 days fr histry f chrnic piid therapy with shrt-acting piids and apprval f up t 6 mnths fr histry f chrnic piid therapy with lngacting piids). Please include dcumentatin f piid dse tapering treatment plan. Page 2 f 10

3 WVP Health Authrity Updated MED Guide Generic Name Strength Dsage Frm Qty/day fr 120 mg MED CODEINE SULFATE 15 MG TABLET CODEINE SULFATE 30 MG TABLET CODEINE SULFATE 60 MG TABLET FENTANYL 12.5 MCG/HR PATCH 1.2 FENTANYL 25 MCG/HR PATCH 0.6 FENTANYL 50 MCG/HR PATCH 0.3 HYDROCODONE/APAP 10MG-325MG TABLET 12 HYDROMORPHONE HCL 2 MG TABLET 15 HYDROMORPHONE HCL 4 MG TABLET 7.5 HYDROMORPHONE HCL 8 MG TABLET 3.75 METHADONE HCL 5 MG TABLET 8 METHADONE HCL 10 MG TABLET 4 MORPHINE SULFATE 10 MG/5 ML SOLN 60 MORPHINE SULFATE 100 MG/5 ML SOLN 6 MORPHINE SULFATE 15 MG TABLET 8 MORPHINE SULFATE 30 MG TABLET 4 MORPHINE SULFATE 15 MG TABLET ER 8 MORPHINE SULFATE 30 MG TABLET ER 4 MORPHINE SULFATE 60 MG TABLET ER 2 OXYCODONE HCL 100 MG/5 ML SOLN 4 OXYCODONE HCL 5 MG TABLET 16 OXYCODONE HCL 7.5 MG TABLET 12 OXYCODONE HCL 10 MG TABLET 8 OXYCODONE HCL 15 MG TABLET 5.33 OXYCODONE HCL 20 MG TABLET 4 OXYCODONE HCL 30 MG TABLET 2.67 Page 3 f 10

4 WVP Health Authrity Updated Name APAP/Cdeine 120/12 mg per 5 ml sl Frmulary Listing Fill Restrictin QL f 240 ml. Max f 1 fill per 180 days. APAP/Cdeine 300/15 mg tabs APAP/Cdeine 300/30 mg tabs APAP/Cdeine 300/60 mg tabs Cdeine Sulfate 15 mg tabs Cdeine Sulfate 30 mg tabs Cdeine Sulfate 60 mg tabs Fentanyl 25 mcg/hr patches PA required. Fentanyl 50 mcg/hr patches PA required. Hydrcdne/APAP 7.5/325 mg per 15 ml sl QL f 240 ml. Max f 1 fill per 180 days. Hydrcdne/APAP 5/325 mg tabs Hydrcdne/APAP 7/325 mg tabs Hydrcdne/APAP 10/325 mg tabs Hydrcdne/Ibuprfen 7.5/200 mg tabs Hydrmrphne 2 mg tabs Hydrmrphne 4 mg tabs Hydrmrphne 8 mg tabs Methadne 5 mg tabs Methadne 10 mg tabs QL per time f 90 tabs in 25 days. Max f 90 days per year. PA required fr patients under 18 and fr all new starts PA required fr patients under 18 and fr all new starts Page 4 f 10

5 WVP Health Authrity Updated Name Mrphine IR 15 mg tabs Mrphine IR 30 mg tabs Mrphine ER 15 mg tabs Mrphine ER 30 mg tabs Mrphine ER 60 mg tabs Oxycdne 5 mg tabs Oxycdne 10 mg tabs Oxycdne 15 mg tabs Oxycdne 20 mg tabs Oxycdne 30 mg tabs Oxycdne/APAP 5/325 mg tabs Oxycdne/APAP 7.5/325 mg tabs Oxycdne/APAP 10/325 mg tabs Fill Restrictin QL per time f 90 tabs in 25 days. Max f 90 days per year. QL per time f 90 tabs in 25 days. Max f 90 days per year. QL per time f 60 tabs in 25 days. Max f 90 days per year. QL per time f 60 tabs in 25 days. Max f 90 days per year. Page 5 f 10

6 WVP Health Authrity Updated Shrt-Acting Opiid (SAO) PA Criteria ***Cntinuatin f therapy requests that d nt meet criteria may be apprved as amended fr up t 60 days t allw fr PA criteria cmpliance r dse tapering*** 1. Is the patient being treated fr an OHP funded cnditin? a. If Yes, mve t questin #2. b. If N, review dcumentatin fr relevant cmrbid cnditins. If there are relevant cmrbid cnditins, mve t questin #2. If there are n relevant cmrbid cnditins, Cat. 1 denial. 2. Is the requested medicatin n the frmulary? a. If Yes, mve t questin #4. b. If N, mve t questin #3. 3. Has patient tried and failed frmulary ptins? a. If Yes, mre t questins #4. b. If N, Cat. 15 denial. 4. Is the requested medicatin being used fr the treatment f pain assciated with cancer r a terminal illness? a. If Yes, Apprve fr 12 mnths. b. If N, mve t questins #5. 5. Is the requested medicatin being used fr the treatment f acute pain assciated with a recent injury r surgery? a. If Yes, Apprve fr up t 90 days. b. If N, mve t questins #6. 6. Has the patient tried and failed (r is the patient currently using) nn-piid treatment alternatives? See page 2 fr examples f nn-piid treatment alternatives. a. If Yes, mve t questin #7. 7. Des the patient have a histry f a suicide attempt within the last 2 years r a suicide attempt using pills anytime? a. If Yes, frward t Medical Directr t assess medical apprpriateness (Pssible Cat. 5 denial). b. If N, mve t questin #8. 8. Des the dsing f the medicatin exceed a 120 mg mrphine equivalent dse (MED) per day? a. If Yes, mve t questin #9. b. If N, mve t questin # Has patient tried and failed medicatin dses under 120 mg MED per day? a. If Yes, mve t questin # Has patient been evaluated by a pain management specialist r has prvider had a cnsultatin with a pain management specialist? a. If Yes, mve t questin # Is there an established pain treatment agreement between patient and prvider? See page 2 fr pain treatment agreement recmmendatins. a. If Yes, mve t questin #12. Page 6 f 10

7 WVP Health Authrity Updated Des the request represent a new start r a cntinuatin f therapy? a. If request is a New Start, Apprve fr up t 90 days. b. If request is a cntinuatin f therapy, mve t questin # Des the prvider submitted dcumentatin indicate that medicatin use has demnstrated an imprvement in patient s functin and pain status? a. If Yes, mve t questin # Has the patient been adherent t their established pain treatment agreement? a. If Yes, Apprve fr 6 mnths. Lng-Acting Opiid (LAO) PA Criteria ***Cntinuatin f therapy requests that d nt meet criteria may be apprved as amended fr up t 6 mnths t allw fr PA criteria cmpliance r dse tapering*** 1. Is the patient being treated fr an OHP funded cnditin? a. If Yes, mve t questin #2. b. If N, review dcumentatin fr relevant cmrbid cnditins. If there are relevant cmrbid cnditins, mve t questin #2. If there are n relevant cmrbid cnditins, Cat. 1 denial. 2. Is the requested medicatin n the frmulary? a. If Yes, mve t questin #4. b. If N, mve t questin #3. 3. Has patient tried and failed frmulary ptins? a. If Yes, mre t questins #4. b. If N, Cat. 15 denial. 4. Is the requested medicatin being used fr the treatment f pain assciated with cancer r a terminal illness? a. If Yes, Apprve fr 12 mnths. b. If N, mve t questins #5. 5. Has the patient tried and failed (r is the patient currently using) nn-piid treatment alternatives? See page 2 fr examples f nn-piid treatment alternatives. a. If Yes, mve t questin #6. 6. Des the patient have a histry f a suicide attempt within the last 2 years r a suicide attempt using pills anytime? a. If Yes, frward t Medical Directr t assess medical apprpriateness (Pssible Cat. 5 denial). b. If N, mve t questin #7. 7. Des the patient s ttal piid use (IR and ER prducts) exceed a 120 mg mrphine equivalent dse (MED) per day? a. If Yes, mve t questin #8. b. If N, mve t questin # Has patient tried and failed medicatin dses under 120 mg MED per day? a. If Yes, mve t questin #9. Page 7 f 10

8 WVP Health Authrity Updated Has patient been evaluated by a pain management specialist r has prvider had a cnsultatin with a pain management specialist? a. If Yes, mve t questin # Is there an established pain treatment agreement between patient and prvider? See page 2 fr pain treatment agreement recmmendatins. a. If Yes, mve t questin # Des the request represent a new start r a cntinuatin f therapy? a. If request is a New Start, Apprve fr up t 90 days. b. If request is a cntinuatin f therapy, mve t questin # Des the prvider submitted dcumentatin indicate that medicatin use has demnstrated an imprvement in patient s functin and pain status? c. If Yes, mve t questin #13. d. If N, frward t Medical Directr t assess medical apprpriateness (Pssible Cat. 5 denial). 13. Has the patient been adherent t their established pain treatment agreement? a. If Yes, Apprve fr 6 mnths. Methadne PA Criteria ***Cntinuatin f therapy requests that d nt meet criteria may be apprved as amended fr up t 6 mnths t allw fr PA criteria cmpliance r dse tapering*** 1. Is the patient being treated fr an OHP funded cnditin? a. If Yes, mve t questin #2. b. If N, review dcumentatin fr relevant cmrbid cnditins. If there are relevant cmrbid cnditins, mve t questin #2. If there are n relevant cmrbid cnditins, Cat. 1 denial. 2. Is the requested medicatin n the frmulary? a. If Yes, mve t questin #4. b. If N, mve t questin #3. 3. Has the patient tried and failed frmulary ptins? a. If Yes, mre t questins #4. b. If N, Cat. 15 denial. 4. Is the requested medicatin being used fr the treatment f pain assciated with cancer r a terminal illness? a. If Yes, Apprve fr 12 mnths. b. If N, mve t questins #5. 5. Has the patient tried and failed nn-piid treatment alternatives, shrt-acting piids, and mrphine sulfate ER tablets? See page 2 fr examples f nn-piid treatment alternatives. a. If Yes, mve t questin #6. 6. Des the patient have a histry f a suicide attempt within the last 2 years r a suicide attempt using pills anytime? a. If Yes, frward t Medical Directr t assess medical apprpriateness (Pssible Cat. 5 denial). b. If N, mve t questin #7. Page 8 f 10

9 WVP Health Authrity Updated Des the patient s ttal piid use (IR and ER prducts) exceed a 120 mg mrphine equivalent dse (MED) per day? a. If Yes, mve t questin #8. b. If N, mve t questin # Has patient tried and failed medicatin dses under 120 mg MED per day? a. If Yes, mve t questin #9. 9. Has patient been evaluated by a pain management specialist r has prvider had a cnsultatin with a pain management specialist? a. If Yes, mve t questin # Is there an established pain treatment agreement between patient and prvider? See page 2 fr pain treatment agreement recmmendatins. a. If Yes, mve t questin # Des the request represent a new start r a cntinuatin f therapy? a. If request is a New Start, Apprve fr up t 90 days. b. If request is a cntinuatin f therapy, mve t questin # Des the prvider submitted dcumentatin indicate that medicatin use has demnstrated an imprvement in patient s functin and pain status? e. If Yes, mve t questin #13. f. If N, frward t Medical Directr t assess medical apprpriateness (Pssible Cat. 5 denial). 13. Has the patient been adherent t their established pain treatment agreement? a. If Yes, Apprve fr 6 mnths. * Special cnsideratin may be given t patients currently n chrnic piid therapy with methadne in whm dse decreases r medicatin discntinuatin may result in destabilizatin, and patient grandfathering may be apprved. Prviders may cntact a WVP HA pharmacist t have the cverage f methadne by the plan cntinued fr patients with a histry f chrnic methadne use. Fentanyl Transdermal Patch PA Criteria ***Cntinuatin f therapy requests that d nt meet criteria may be apprved as amended fr up t 6 mnths t allw fr PA criteria cmpliance r dse tapering*** 1. Is the patient being treated fr an OHP funded cnditin? a. If Yes, mve t questin #2. b. If N, review dcumentatin fr relevant cmrbid cnditins. If there are relevant cmrbid cnditins, mve t questin #2. If there are n relevant cmrbid cnditins, Cat. 1 denial. 2. Is the patient piid-tlerant? Opiid-tlerant is defined as patients wh are taking at least 60 mg/day f ral mrphine, transdermal fentanyl 25 mcg/hur, ral xycdne 30 mg/day, ral hydrmrphne 8 mg/day, ral xymrphne 25 mg/day, r equianalgesic dse f anther piid fr at least ne week. a. If Yes, mve t questin #3. b. If N, Cat. 3 denial and Cat. 5 denial. Fentanyl transdermal patches are nt indicated fr piid-naïve patients. Page 9 f 10

10 WVP Health Authrity Updated Is the medicatin being used fr the treatment f chrnic pain severe enugh t require daily, arund-the-clck, lngterm piid treatment fr which alternative treatments are inadequate? a. If Yes, mve t questin #4. b. If N, Cat. 3 denial and Cat. 5 denial. Fentanyl transdermal patches are nly indicated fr the treatment f chrnic pain that meets this criteria. 4. Is the medicatin being used fr the treatment f pain assciated with cancer r a terminal illness? a. If Yes, Apprve fr 12 mnths. b. If N, mve t questins #5. 5. Des the dsing f the medicatin exceed the 50 mcg/hr patches? a. If Yes, mve t questin #6. b. If N, mve t questin #8. 6. Has patient tried and failed medicatin dses under the 50 mcg/hr patches? a. If Yes, mve t questin #7. 7. Has patient been evaluated by a pain management specialist r has prvider had a cnsultatin with a pain management specialist? a. If Yes, mve t questin #8. 8. Is the medicatin dsing interval within the FDA apprved dsing? FDA apprved dsing interval fr fentanyl transdermal patches is every 48 t 72 hurs. a. If Yes, mve t questin #9. b. If N, Cat. 3 denial and Cat. 5 denial. 9. Is there an established pain treatment agreement between patient and prvider? See page 2 fr pain treatment agreement recmmendatins. a. If Yes, mve t questin # Des the request represent a new start r a cntinuatin f therapy? a. If request is a New Start, Apprve fr up t 90 days. b. If request is a cntinuatin f therapy, mve t questin # Des the prvider submitted dcumentatin indicate that medicatin use has demnstrated an imprvement in patient s functin and pain status? g. If Yes, mve t questin #12. h. If N, frward t Medical Directr t assess medical apprpriateness (Pssible Cat. 5 denial). 12. Has the patient been adherent t their established pain treatment agreement? a. If Yes, Apprve fr 6 mnths. Guide t Denial Categries Categry 1 Categry 3 Categry 5 Categry 15 Reasn fr Denial The cnditin is nt n a funded line The use f the medicatin is cnsidered experimental/ investigatinal (usually applies t ff-label use f a medicatin) Nt medically apprpriate Frmulary medicatins have nt been exhausted Page 10 f 10