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Oxycontin — Blue Cross Blue Shield of Illinois

sickle cell anemia

Initial criteria

  • Target agent will be approved when ONE of the following is met:
  • 1. Continuation of therapy: patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed OR
  • 2. Patient has a diagnosis of chronic cancer pain due to an active malignancy OR
  • 3. Patient is enrolled in a hospice program or meets hospice criteria for life expectancy ≤ 6 months OR
  • 4. Prescriber requests palliative care or compassionate use where benefits of pain relief and comfort outweigh risks OR
  • 5. Patient has a diagnosis of sickle cell anemia OR
  • 6. Patient is undergoing treatment of chronic non-cancer pain AND meets ALL of the following (details continue on next page).

Reauthorization criteria

  • Continuation of therapy criteria: patient has been treated with requested agent within past 90 days and is at risk if therapy is changed.