fentanyl transdermal patch (generic Duragesic) — United Healthcare

Preferred products

• morphine sulfate controlled-release tablets (generic MS Contin)

Initial criteria

• Prescriber attests to BOTH of the following: • Patient has been screened for substance abuse/opioid dependence • Pain is moderate to severe and expected to persist for an extended period of time (chronic)
• Treatment goals are defined and include estimated duration of treatment (must document treatment goals)
• Patient has been screened for underlying depression and/or anxiety. If applicable, any underlying conditions have been or will be addressed
• ONE of the following: (a) BOTH of the following: i. The patient is being treated for moderate to severe chronic pain that is non-neuropathic -AND- ii. ONE of the following: a) Prior to the start of therapy with the long-acting opioid, the patient has failed an adequate (minimum of 4 week) trial of a short-acting opioid (document drug(s) and date of trial) -OR- b) The patient is new to the plan (coverage effective date ≤ 120 days) and is currently established on the requested long-acting opioid -OR- (b) BOTH of the following: i. The patient is being treated for moderate to severe neuropathic pain (e.g., neuralgia, neuropathy) -AND- ii. ONE of the following: a) BOTH of the following: 1) Unless contraindicated, inadequate response to 8 weeks of therapeutic-dose gabapentin (document date of trial) 2) Unless contraindicated, inadequate response to ≥6 weeks of tricyclic antidepressant titrated to maximum tolerated dose (document drug and trial date) -OR- b) The patient is new to the plan (coverage effective ≤120 days) and currently established on requested long-acting opioid -OR- (c) ALL of the following: i. The patient is being treated for moderate to severe fibromyalgia -AND- ii. Submission of chart notes showing patient is currently established on long-acting opioid -AND- iii. Chart notes showing benefit from opioid therapy
• History of failure, contraindication or intolerance to morphine sulfate controlled-release tablets (generic MS Contin) (Document date of trial)

Reauthorization criteria

• Documented meaningful improvement in pain and function when assessed against treatment goals (document improvement in function or pain score improvement)
• Document rationale for not tapering or discontinuing opioid if treatment goals are not being met
• Prescriber attests to BOTH of the following: • Patient has been screened for substance abuse/opioid dependence • Pain is moderate to severe and expected to persist for an extended period of time (chronic)

Approval duration

6 months