fentanyl transdermal patch (generic Duragesic) 25 mcg/hr — United Healthcare

Initial criteria

• Prescriber attests to BOTH of the following: patient screened for substance abuse/opioid dependence AND pain is moderate to severe and expected to persist for an extended period (chronic)
• Treatment goals are defined and include estimated duration of treatment
• Patient screened for underlying depression and/or anxiety; if applicable, underlying conditions have been or will be addressed
• AND ONE of the following:
• (a) BOTH of the following: patient being treated for moderate to severe chronic non-neuropathic pain AND EITHER (i) failed adequate (≥4 week) trial of a short-acting opioid (document drugs and date of trial) OR (ii) new to the plan (coverage ≤120 days) and currently established on the requested long-acting opioid
• OR (b) BOTH of the following: patient being treated for moderate to severe neuropathic pain (e.g., neuralgia, neuropathy) AND EITHER BOTH of the following (no adequate response to 8 weeks gabapentin titrated to therapeutic dose AND no adequate response to ≥6 weeks tricyclic antidepressant to maximum tolerated dose, document drug/date) OR new to the plan (coverage ≤120 days) and currently established on requested long-acting opioid
• OR (c) ALL of the following: patient being treated for moderate to severe fibromyalgia; submission of medical records documenting patient established on long-acting opioid; submission documenting benefit from opioid therapy