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Oxycontin — Point32Health

chronic pain

Preferred products

  • Xtampza ER

Initial criteria

  • Both of the following: (a) The patient is diagnosed with sickle-cell, cancer-related, or end-of-life pain AND (b) If requesting Oxycontin or oxycodone ER, the patient has tried and failed or has a contraindication to Xtampza ER
  • OR All of the following: (a) The patient has a diagnosis of chronic pain AND (b) The patient has had an inadequate response to a generic immediate release opioid AND (c) The patient signed a pain agreement consistent with the American Academy of Pain Management guidelines AND (d) The analgesic is prescribed by or in consultation with a pain specialist, addiction specialist, palliative care specialist, hematologist/oncologist, physiatrist, rheumatologist or headache specialist (board certified) OR there is a plan for the patient to be referred to such a specialist OR rationale provided why the patient is not a candidate to see a specialist AND (e) The risks of opioid analgesics have been discussed with the patient AND (f) The provider has a plan to monitor for signs of misuse, abuse, and addiction during therapy AND (g) For renewals, provider has a taper plan in place or rationale as to why a dose taper is not appropriate at this time AND (h) If requesting Oxycontin or oxycodone ER, the patient has tried and failed or has a contraindication to Xtampza ER

Reauthorization criteria

  • Both of the following: (a) The patient is diagnosed with sickle-cell, cancer-related, or end-of-life pain AND (b) If requesting Oxycontin or oxycodone ER, the patient has tried and failed or has a contraindication to Xtampza ER
  • OR All of the following: (a) The patient has a diagnosis of chronic pain AND (b) The patient signed a pain agreement consistent with the American Academy of Pain Management guidelines AND (c) The analgesic is prescribed by or in consultation with a pain specialist, addiction specialist, palliative care specialist, hematologist/oncologist, physiatrist, rheumatologist or headache specialist (board certified) OR there is a plan for the patient to be referred to such a specialist OR rationale provided why the patient is not a candidate to see a specialist AND (d) The risks of use of a high dose schedule II, III, or IV analgesic have been discussed with the patient AND (e) The provider has a plan to monitor for signs of misuse, abuse, and addiction during therapy AND (f) The provider has a taper plan in place or rationale as to why a dose taper is not appropriate at this time AND (g) If requesting Oxycontin or oxycodone ER, the patient has tried and failed or has a contraindication to Xtampza ER

Approval duration

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