Hydromorphone extended-release tablets (generic to discontinued Exalgo) — Cigna

Pain severe enough to require daily, around-the-clock, long-term opioid treatment

Initial criteria

Approve for 1 year if the patient meets ONE of the following (A, B, C, or D):
A) Patient has a cancer diagnosis; OR
B) Patient is in a hospice program, end-of-life care, or palliative care; OR
C) Patient meets BOTH of the following (i and ii):
i) Patient has diagnosis of sickle cell disease; AND
ii) The medication is prescribed by or in consultation with a hematologist; OR
D) Patient meets ALL of the following (i, ii, iii, iv, v, vi, and vii):
i. Patient is not opioid-naïve; AND
ii. According to the prescriber, non-opioid therapies have been optimized and are being used in conjunction with opioid therapy; AND
iii. According to the prescriber, patient's history of controlled substance prescriptions has been checked using the state prescription drug monitoring program (PDMP); AND
iv. According to the prescriber, risks (e.g., addiction, overdose) and realistic benefits of opioid therapy have been discussed with the patient; AND
v. According to the prescriber, treatment plan (including goals for pain and function) is in place and reassessments (including pain levels and function) are scheduled at regular intervals; AND
vi. According to the prescriber, need for a naloxone prescription has been assessed and naloxone has been ordered, if necessary; AND
vii. According to the prescriber, need for periodic toxicology testing has been assessed and ordered, if necessary.

1 year