Xtampza ER — United Healthcare

Preferred products

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

Initial criteria

• Prescriber attests to BOTH of the following: Patient has been screened for substance abuse/opioid dependence AND 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 AND if applicable, any underlying conditions have been or will be addressed
• ONE of the following applies:
• For non-neuropathic chronic pain: BOTH of the following: (i) 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
• For neuropathic pain: BOTH of the following: (i) 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, patient has not exhibited an adequate response to 8 weeks of treatment with gabapentin titrated to a therapeutic dose (Document date of trial) AND (2) Unless contraindicated, patient has not exhibited an adequate response to at least 6 weeks of treatment with a tricyclic antidepressant titrated to the maximum tolerated dose (Document drug 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
• For fibromyalgia: ALL of the following: (i) Patient is being treated for moderate to severe fibromyalgia AND (ii) Submission of medical records documenting patient is currently established on a long-acting opioid AND (iii) Submission of medical records documenting patient has experienced a benefit from opioid therapy
• ONE of the following: (a) History of failure, contraindication, or intolerance to ONE of the following (Document date of trial): morphine sulfate controlled-release capsules (generic Avinza) OR morphine sulfate sustained-release capsules (generic Kadian) OR (b) The patient has risk factors for substance abuse
• Authorization duration 6 months for non-cancer and non-end of life pain up to dose allowed by supply limit review; if patient does not meet criteria, may grant 90-day authorization for transition to alternative treatment

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 AND Pain is moderate to severe and expected to persist for an extended period of time (chronic)
• Authorization duration 6 months for non-cancer and non-end of life pain up to dose allowed by supply limit review; if patient does not meet criteria, may grant 90-day authorization for transition

Approval duration

6 months; may allow 90-day transition authorization