methadone tablet — Point32Health

moderate to severe pain requiring continuous, around-the-clock opioid analgesic therapy

Initial criteria

The patient has a documented diagnosis of moderate to severe pain requiring continuous, around-the-clock treatment with an opioid analgesic
The patient is not opioid-naïve
For non-cancer patients: The patient has had an ECG showing a normal QTc interval
Has had an inadequate response, intolerance, or contraindication to two other long-acting opioid analgesics OR the provider submits a clinical rationale for use of oral methadone over other long-acting opioid analgesics
The patient signed a pain management agreement consistent with the American Academy of Pain Management guidelines
The risks of opioid analgesics have been discussed with the patient
The provider has a plan in place to monitor the patient for misuse and addiction during therapy
For injection only: Provider submits a clinical rationale for use of injection over oral formulation

6 months (12 months if sickle-cell, cancer-related, or end-of-life pain)