Skip to content
The Policy VaultThe Policy Vault

Xtampza er — Blue Cross Blue Shield of Montana

sickle cell anemia

Initial criteria

  • 1. The requested agent is eligible for continuation of therapy AND both of the following: (a) the prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed.
  • OR 2. The patient has a diagnosis of chronic cancer pain due to an active malignancy.
  • OR 3. The patient is enrolled in a hospice program or meets hospice criteria for life expectancy of six months or less.
  • OR 4. The prescriber is requesting palliative care or compassionate use (benefits of pain relief and patient comfort outweigh opioid risk).
  • OR 5. The patient has a diagnosis of sickle cell anemia.
  • OR 6. The patient is undergoing treatment of chronic non-cancer pain and ALL of the following apply (criteria continue beyond shown text).

Reauthorization criteria

  • Eligible for continuation of therapy if treated within past 90 days and at risk if therapy is changed.