Levorphanol — CareFirst (Caremark)
Pain associated with cancer
Initial criteria
- For pain associated with cancer, sickle cell disease, a terminal condition, or pain being managed through hospice or palliative care: authorization may be granted when the requested drug is prescribed for these indications.
- For acute pain: 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: the patient requires treatment 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 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 to patient safety.
Reauthorization criteria
- For continued therapy (chronic pain): the patient’s pain and function demonstrate clinically meaningful improvement that outweighs risks to patient safety; patient continues to be monitored for opioid use disorder.