codeine/phenylephrine/promethazine — United Healthcare
Cough and cold requiring opioid-containing product
Initial criteria
- Prescriber attests they are aware of FDA labeled contraindications regarding use of opioid-containing cough and cold products in patients less than 18 years of age and feels the treatment with the requested product is medically necessary (Document rationale for use)
- AND Patient does not have a comorbid condition that may impact respiratory depression (e.g., asthma or other chronic lung disease, sleep apnea, body mass index > 30)
- AND Patient has tried and failed at least one non-opioid containing cough and cold remedy
Approval duration
1 month