Methadone — Medica

Initial criteria

• For Pain Severe Enough to Require Daily, Around-the-Clock, Long-Term Opioid Treatment: 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) 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. Patient is not opioid-naïve; AND ii. Non-opioid therapies have been optimized and are being used in conjunction with opioid therapy, according to the prescriber; AND iii. Patient’s controlled substance prescriptions have been checked using the state prescription drug monitoring program (PDMP); AND iv. Risks (e.g., addiction, overdose) and realistic benefits of opioid therapy have been discussed with the patient; AND v. Treatment plan including goals for pain and function is in place and reassessments scheduled at regular intervals; AND vi. Need for a naloxone prescription has been assessed and ordered if necessary; AND vii. Need for periodic toxicology testing has been assessed and ordered if necessary.
• For Opioid Addiction (Dependence): Approve for 1 year if ONE of the following (A or B) is met:
• A) Methadone is dispensed by an opioid treatment program certified by the Substance Abuse and Mental Health Services Administration and approved by the designated state authority; OR
• B) Methadone is being prescribed during an emergency period of ≤ 3 days while definitive care for the addiction is being sought in an appropriately licensed facility.

Approval duration

1 year