requested agent — Blue Cross Blue Shield of Texas

Preferred products

• Xtampza

Initial criteria

• Diagnosis of stage four advanced metastatic cancer or an associated condition (chart notes required)
• The use of the requested agent is consistent with best practices for treatment of stage four advanced metastatic cancer or associated condition, supported by evidence-based literature, and FDA approved OR
• Patient 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, effectiveness, diminished effect, or an adverse event (chart notes required) OR
• Patient has intolerance or hypersensitivity to Xtampza not expected to occur with requested agent (chart notes required) OR
• Patient has an FDA labeled contraindication to Xtampza not expected to occur with requested agent (chart notes required) OR
• Xtampza expected to be ineffective or cause significant barrier to adherence, worsen comorbid condition, decrease functional ability, or cause harm (chart notes required) OR
• Xtampza not in best interest of patient based on medical necessity (chart notes required) OR
• Patient has tried another prescription drug in same pharmacologic class or with same mechanism as Xtampza discontinued due to lack of efficacy or adverse event (chart notes required)
• A formal consultative evaluation has been conducted including diagnosis, complete medical history (previous and current pharmacologic and non-pharmacologic therapy), and 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 the following: (1) patient not concurrently using benzodiazepine OR (2) supported use of opioids with a benzodiazepine

Reauthorization criteria

• Continuation may be approved when above ongoing monitoring and assessment criteria continue to be met at reauthorization

Approval duration

12 months