Xtampza ER — United Healthcare
Non-cancer and non-end of life pain
Preferred products
- fentanyl transdermal patch (generic Duragesic) 12-100 mcg/hr
- methadone
- morphine sulfate controlled-release tablets (generic MS Contin)
Initial criteria
- Prescriber attests to BOTH of the following: patient screened for substance abuse/opioid dependence AND pain 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) OR (ii) new to the plan (coverage ≤120 days) and currently established on 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 at maximum tolerated dose, document drug/date) OR new to the plan (coverage ≤120 days) and currently established on requested long-acting opioid