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Belbuca — CareFirst (Caremark)

Chronic pain severe and persistent enough to require extended treatment with a daily opioid analgesic

Initial criteria

  • Authorization may be granted when the requested drug is being prescribed for pain associated with cancer, sickle cell disease, a terminal condition, or pain being managed through hospice or palliative care.
  • For chronic pain, authorization may be granted when all of the following are met:
  • The patient can safely take the requested dose based on their history of opioid use.
  • The patient has been evaluated and will be monitored regularly for the development of opioid use disorder.
  • The patient's pain will be reassessed in the first month after the initial prescription or any dose increase AND every 3 months thereafter to ensure that clinically meaningful improvement in pain and function outweigh risks.
  • The patient meets ONE of the following: continuation of therapy for a patient who has been receiving an extended-release opioid for at least 30 days OR the patient has taken an immediate-release opioid for at least one week.
  • If the request is for a methadone product, it is NOT being prescribed for detoxification treatment or as part of maintenance treatment for opioid/substance abuse or addiction.