Non-preferred opioid (when compared to Xtampza) — Blue Cross Blue Shield of New Mexico

Preferred products

• Xtampza

Initial criteria

• Condition related to stage four advanced metastatic cancer [chart notes required] AND use is consistent with best practices supported by evidence-based literature and FDA approval OR patient is currently being treated with and stable on the requested agent [chart notes required] OR patient has tried and had inadequate response to Xtampza [chart notes required] OR Xtampza discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR patient has intolerance or hypersensitivity to Xtampza [chart notes required] OR FDA labeled contraindication to Xtampza [chart notes required] OR Xtampza expected ineffective, causes adherence barrier, worsens comorbid condition, decreases functional ability, or causes harm [chart notes required] OR Xtampza not in best interest based on medical necessity [chart notes required] OR patient tried another drug in same class as Xtampza that was discontinued due to lack of efficacy or adverse event [chart notes required]
• Formal, consultative evaluation conducted including ALL: diagnosis, complete medical history (previous/current pharmacological and non-pharmacological therapy), assessment of need for continued opioid therapy [chart notes required]
• Prescriber has reviewed member’s controlled substance records in PDMP
• Patient is routinely (at least every 3 months) assessed for function, pain status, and opioid dose
• ONE of: patient not concurrently using benzodiazepine OR supported use of opioids with benzodiazepine

Approval duration

12 months