Nucynta — Blue Cross Blue Shield of Texas

Initial criteria

• Target Agent(s) will be approved when ONE of the following is met:
• 1. Requested agent eligible for continuation of therapy AND prescriber states patient has been treated with requested agent within past 90 days AND is at risk if therapy is changed OR
• 2. Patient has diagnosis of chronic cancer pain due to active malignancy OR
• 3. Patient is enrolled in 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 opioid risk OR
• 5. Patient has diagnosis of sickle cell anemia OR
• 6. Patient undergoing treatment of chronic non-cancer pain AND ALL of following conditions met (additional details continue beyond this section)