Oxycodone tablets — CareFirst (Caremark)

Initial criteria

• Subject to 7-day acute pain duration limit with morphine milligram equivalent (MME) limit
• Initial 1 month and 3 month limits: ≤ 90 MME/day
• Post 1 month and post 3 month limits: ≤ 200 MME/day
• Quantity limits per month and 3-month supply apply as listed per strength and formulation

Reauthorization criteria

• Reauthorization may be granted when ongoing need for therapy is documented for cancer pain, sickle cell disease, terminal, hospice, or palliative care conditions
• Chronic pain may be reauthorized per defined duration limits

Approval duration

Pain associated with cancer, sickle cell disease, terminal condition, or hospice/palliative care: 12 months; Chronic pain: 6 months; Acute pain: 1 month