Actiq — CareFirst (Caremark)

Breakthrough pain in cancer patients with underlying cancer pain who are already receiving and who are tolerant to around-the-clock opioid therapy

Initial criteria

The requested drug is prescribed for the management of breakthrough pain in a cancer patient with underlying cancer pain
Documentation must support a diagnosis of cancer-related pain and list the type of cancer; ICD diagnosis code must support the cancer-related diagnosis
The patient is currently receiving and will continue to receive around-the-clock opioid therapy for underlying cancer pain
The patient is opioid tolerant, defined as taking for one week or longer at least 60 mg oral morphine per day, 25 mcg transdermal fentanyl per hour, 30 mg oral oxycodone per day, 8 mg oral hydromorphone per day, 25 mg oral oxymorphone per day, 60 mg oral hydrocodone per day, or an equianalgesic dose of another opioid
The drug is not used in opioid non-tolerant patients
The drug is not used for acute or postoperative pain, including headache/migraine, dental pain, or in the emergency department
The prescriber and pharmacy must comply with the TIRF REMS program

All initial criteria continue to be met
If additional quantities are requested, the patient meets ONE of the following: the dose of a concomitant long-acting analgesic is being increased OR the dose of the long-acting analgesic cannot be increased and additional breakthrough pain medication is needed

12 months