Fentora — CareFirst (Caremark)

Initial criteria

• Patient has a diagnosis of cancer-related pain, documented by chart notes or other supporting documentation including type of cancer and ICD diagnosis code supporting the cancer-related diagnosis
• Patient is currently receiving, and will continue to receive, around-the-clock opioid therapy for underlying cancer pain
• Patient is opioid tolerant (taking for one week or longer an around-the-clock opioid regimen consisting of at least 60 mg oral morphine per day, at least 25 mcg transdermal fentanyl per hour, at least 30 mg oral oxycodone per day, at least 8 mg oral hydromorphone per day, at least 25 mg oral oxymorphone per day, at least 60 mg oral hydrocodone per day, or an equianalgesic dose of another opioid)
• Drug must be prescribed only by healthcare professionals knowledgeable about the use of opioids and mitigation of associated risks
• Drug will not be used in opioid non‑tolerant patients or for acute or postoperative pain (including headache/migraine, dental pain, or emergency department use)

Reauthorization criteria

• Continuation of therapy is appropriate if patient continues to meet the initial criteria including documentation of ongoing cancer‑related pain and continued around‑the‑clock opioid therapy
• If additional quantities requested, patient must meet ONE of the following: (a) patient's dose of concomitant long‑acting analgesic is being increased OR (b) additional quantities are needed because the dose of the long‑acting analgesic cannot be increased

Approval duration

12 months