requested opioid agent (non-preferred vs Xtampza) — Blue Cross Blue Shield of Illinois

Preferred products

• Xtampza

Initial criteria

• Diagnosis must be related to stage four advanced metastatic cancer [chart notes required] AND use is consistent with best practices for such cancer, supported by evidence-based literature and FDA approval OR
• Patient is currently treated and stable on the requested agent [chart notes required] OR
• Patient tried and had an inadequate response to Xtampza [chart notes required] OR
• Xtampza was discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
• Intolerance or hypersensitivity to Xtampza not expected with requested agent [chart notes required] OR
• FDA labeled contraindication to Xtampza not expected with requested agent [chart notes required] OR
• Xtampza expected to be ineffective or to cause significant barrier, worsen comorbid condition, decrease daily functional ability, cause adverse reaction, or physical/mental harm [chart notes required] OR
• Xtampza not in best interest based on medical necessity [chart notes required] OR
• Tried another prescription drug in same pharmacologic class/mechanism as Xtampza and discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] AND
• A formal consultative evaluation includes ALL of the following: diagnosis; complete medical history including pharmacological/non-pharmacological therapy; need for continued opioid therapy assessed [chart notes required] AND
• Prescriber has reviewed state PDMP controlled substance record AND
• Patient is routinely (≥ every 3 months) assessed for function, pain status, and opioid dose AND
• ONE of the following: patient not concurrently using benzodiazepine OR use with benzodiazepine supported

Approval duration

12 months