Methadone tablets (e.g., Diskets®, Dolophine®, Methadose™, generic) — Cigna

Initial criteria

• Approve for 1 year if ONE of the following (A, B, C, or D) is met:
• 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) Medication is prescribed by or in consultation with a hematologist; OR
• D) Patient meets ALL of the following (i through 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
• Note: Examples of non-opioid therapies include non-opioid medications (e.g., NSAIDs, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, antiseizure medications), physical therapy, exercise therapy, weight loss, and cognitive behavioral 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.

Approval duration

1 year