Fentanyl citrate buccal tablet — Highmark

Initial criteria

• The immediate release fentanyl is being used for the management of breakthrough cancer pain in patients with malignancies
• AND the member is currently receiving and is tolerant to long-acting narcotic therapy (e.g., Oxycontin, morphine sulfate sustained release, fentanyl transdermal patch, etc.)
• AND the member meets one of the following criteria:
• 1. The member has difficulty or discomfort while swallowing (dysphagia), esophagitis, or uncontrolled nausea and vomiting
• OR 2. The member is unable to take one short-acting single-entity narcotic (oxycodone, hydromorphone, morphine sulfate, etc.)

Reauthorization criteria

• The immediate release fentanyl is being used for the management of breakthrough cancer pain in patients with malignancies
• AND the member is currently receiving and tolerant to long-acting narcotic therapy (e.g., Oxycontin, morphine sulfate sustained release, fentanyl transdermal patch, etc.)
• AND the member meets one of the following criteria:
• 1. The member has difficulty or discomfort while swallowing (dysphagia), esophagitis, or uncontrolled nausea and vomiting
• OR 2. The member is unable to take one short-acting single-entity narcotic (oxycodone, hydromorphone, morphine sulfate, etc.)
• AND the prescriber provides documentation that the medication is effective in treating the member’s breakthrough pain and the benefits outweigh harms of continued opioid therapy

Approval duration

6 months