Actiq (oral transmucosal fentanyl citrate – Teva, generic) — Cigna

Breakthrough pain in a patient with cancer

Initial criteria

Approve for 1 year if the patient meets BOTH of the following (A and B):
A) Patient meets ONE of the following conditions (i or ii):
i. Patient is unable to swallow, has dysphagia, esophagitis, mucositis, or uncontrollable nausea/vomiting; OR
ii. Patient is unable to take two other short-acting narcotics secondary to allergy or severe adverse events;
AND
B) Patient is on or will be on an oral or transdermal long-acting narcotic, or the patient is on an intravenous, subcutaneous, or spinal (intrathecal, epidural) narcotic.

1 year