Levorphanol tablets 1 mg — CareFirst (Caremark)
Sickle cell disease
Initial criteria
- For pain associated with cancer, sickle cell disease, a terminal condition, or hospice/palliative care: Authorization may be granted when the requested drug is prescribed for such pain.
- For acute pain: Authorization may be granted when the patient requires treatment for acute pain severe enough to require an opioid analgesic AND 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.
- For chronic pain: Authorization may be granted when the drug is prescribed for chronic pain severe enough to require an opioid analgesic AND 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 within the first month after the initial prescription or any dose increase AND every 3 months thereafter to ensure clinically meaningful improvement in pain and function outweighs risks to patient safety.
Reauthorization criteria
- For chronic pain continuation: Pain and function have been reassessed and remain clinically improved such that the benefits continue to outweigh risks.