buprenorphine patch (generic Butrans) — United Healthcare

Preferred products

• Belbuca
• buprenorphine patch (generic Butrans)

Initial criteria

• A. Cancer or End of Life (life expectancy < 2 years):
• 1. Belbuca and buprenorphine patch (generic Butrans) will be approved when the patient is being treated for pain due to active cancer diagnosis or end of life related pain (document cancer diagnosis or, for end of life, expectancy < 2 years).
• 2. Butrans (brand only) will be approved when BOTH of the following are met:
• a. Patient is being treated for pain due to active cancer diagnosis or end of life related pain (document cancer diagnosis or, for end of life, expectancy < 2 years)
• AND
• b. Patient has a history of failure after a 30-day trial, contraindication, or intolerance to BOTH of the following:
• (1) Belbuca
• (2) buprenorphine patch (generic Butrans)
• B. Non-cancer pain:
• 1. Belbuca and buprenorphine patch (generic Butrans) will be approved when ALL of the following criteria are met:
• (1) Patient is being treated for pain severe enough to require daily, around-the-clock, longer-term opioid treatment.
• AND
• (2) Prescriber attests to ALL of the following:
• (a) Pain is moderate to severe and expected to persist for an extended period of time
• (b) Pain is chronic
• (c) Medication is not being used for opioid dependence
• (d) Dose does not exceed the maximum recommended dose per product label
• AND
• (3) The patient is not receiving other long-acting opioids concurrently.
• 2. Butrans (brand only) will be approved when ALL of the following criteria are met:
• (1) Patient is being treated for pain severe enough to require daily, around-the-clock, longer-term opioid treatment.
• AND
• (2) Prescriber attests to ALL of the following:
• (a) Pain is moderate to severe and expected to persist for an extended period of time
• (b) Pain is chronic
• (c) Medication is not being used for opioid dependence
• (d) Dose does not exceed the maximum recommended dose per product label
• AND
• (3) The patient is not receiving other long-acting opioids concurrently.
• AND
• (4) The patient has a history of failure after a 30-day trial, contraindication or intolerance to BOTH of the following:
• (a) Belbuca
• (b) buprenorphine patch (generic Butrans)

Reauthorization criteria

• Belbuca or Butrans (brand and generic) will be reauthorized when ALL of the following are met:
• 1. Prescriber attests to ALL of the following:
• • Treatment goals are defined, including estimated duration of treatment.
• • Treatment plan includes use of a non-opioid analgesic and/or nonpharmacologic intervention.
• • Patient has been screened for substance abuse/opioid dependence.
• • If used with comorbidities or concurrently with benzodiazepine or other CNS depressants, prescriber has completed an assessment of increased risk for respiratory depression.
• • Pain is moderate to severe and expected to persist for an extended period of time.
• • Pain is chronic.
• • Pain is not postoperative (unless patient already receiving chronic opioid therapy prior to surgery or postoperative pain expected to be moderate to severe and persist for an extended period).
• AND
• (a) Patient demonstrates meaningful improvement in pain and function (documented improvement in function or pain score).
• AND
• (b) Identify rationale for not tapering and discontinuing opioid (document rationale).
• 2. Dose does not exceed maximum dose recommended by product label (document total daily dose).

Approval duration

Cancer/end-of-life pain: 24 months; Non-cancer pain: 6 months initial, 12 months reauthorization