Oxycontin (oxycodone ER) 80 mg — Medical Mutual

Preferred products

• generic oxycodone ER 80 mg

Initial criteria

• Prescribed by or in consultation with a physician who specializes in the condition being treated
• Member age ≥ 11 years
• Pain evaluated by one or more physicians specialized in the area of pain or a pain specialist
• Pain requires around-the-clock treatment
• Provider states member is not a candidate for other non-narcotic pain medication or drug-free alternatives
• Provider has a pain management contract with the patient
• Member is not opioid naïve AND lower doses of oxycodone ER were ineffective AND member is tolerating ≥ 120 morphine equivalents of oxycodone ER
• If taking benzodiazepine or muscle relaxant concurrently, prescriber attests continuation is clinically necessary
• Provider supplies diagnosis of chronic pain with signs, symptoms, and causes
• Provider supplies documentation of periodic functional assessments, progression of goals, and evaluation of addiction/abuse/diversion risk (e.g., Opioid Risk Tool, SOAPP, urine screenings)
• Provider has prescribed or will prescribe naloxone rescue medication AND patient has been trained to use it
• Prescriber attests to reviewing controlled substance medication history via OARRS (or respective state PDMP) and will continue to check as recommended
• Provider verifies no concurrent substance abuse treatments prescribed (e.g., Suboxone, Vivitrol, oral naloxone, buprenorphine)
• Provider is aware member may be limited to filling opiates only from their office
• If requested product is brand Oxycontin 80 mg, patient has tried generic oxycodone ER 80 mg AND cannot use generic due to formulation differences in inactive ingredients

Reauthorization criteria

• All initial criteria are met
• Member’s pain is improving

Approval duration

Hospice/cancer/terminal: indefinite; Chronic pain: 1 year