Xtampza ER — United Healthcare
Cancer or end of life related pain (< 2 year life expectancy)
Preferred products
- fentanyl transdermal patch (generic Duragesic) 12 mcg/hr
- fentanyl transdermal patch (generic Duragesic) 25 mcg/hr
- fentanyl transdermal patch (generic Duragesic) 50 mcg/hr
- fentanyl transdermal patch (generic Duragesic) 75 mcg/hr
- fentanyl transdermal patch (generic Duragesic) 100 mcg/hr
- methadone
- morphine sulfate controlled-release tablets (generic MS Contin)
Initial criteria
- Patient requires treatment with opioids due to active cancer diagnosis or end of life related pain (document cancer diagnosis or expectancy < 2 years)
- AND ONE of the following:
- History of failure, contraindication or intolerance to morphine sulfate controlled-release tablets (generic MS Contin) (document date of trial)
- OR Patient is established on pain therapy with the requested medication for cancer-related or end of life pain (< 2 years life expectancy)
- OR Request is for hydrocodone ER tablets (generic Hysingla ER), Hysingla ER, oxycodone controlled-release (authorized generic for OxyContin), OxyContin or Xtampza ER and the patient has risk factors for substance abuse
Approval duration
24 months (90-day transition period may be granted)