Oxymorphone ER (generic) — Medica

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

Initial criteria

Approve for 1 year if ONE of the following (A–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) BOTH of the following:
i) Patient has diagnosis of sickle cell disease; AND
ii) Medication prescribed by or in consultation with a hematologist; OR
D) 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; AND
iii. Prescriber has checked the patient's controlled substance prescriptions using the state PDMP; AND
iv. Risks (e.g., addiction, overdose) and realistic benefits of opioid therapy have been discussed with the patient; AND
v. Treatment plan with goals for pain and function is in place and reassessments are scheduled at regular intervals; AND
vi. Need for a naloxone prescription has been assessed and naloxone ordered if necessary; AND
vii. Need for periodic toxicology testing has been assessed and ordered if necessary

1 year