Subsys (fentanyl sublingual spray – West Therapeutic Development) — Cigna

Preferred products

• fentanyl citrate oral transmucosal lozenge (Actiq, generic)
• Fentora

Initial criteria

• 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 intravenous, subcutaneous, or spinal (intrathecal, epidural) narcotics; AND
• C) Patient meets ONE of the following conditions (i or ii): i. The patient has tried two of the following, if two are formulary (or one if only one is formulary or none if none are formulary): fentanyl citrate oral transmucosal lozenge (Actiq, generic) or Fentora [verification of therapies required]; OR ii. In patients who cannot tolerate the sugar content of fentanyl citrate oral transmucosal lozenge (Actiq, generic), the patient has tried Fentora, if Fentora is formulary [verification of therapies required].

Approval duration

6 months