Fentanyl Citrate - Providers – Amerigroup

Market
FL &
FL
FL
FHK* MMA LTC
Applicable
X
NA
NA
Market Applicability/Effective Date
GA KS KY
LA
MD NJ NV
X
X
X
X
X
X
X
NY
TN
TX
WA
X
NA
NA
X
*FHK- Florida Healthy Kids
Medication
Comments
Fentanyl Citrate lozenges
Subject to quantity limits
OVERRIDE(S)
Prior authorization of benefits
APPROVAL DURATION AND QUANTITY LIMITS
One year
Maximum quantity limit allowed: 120 lozenges
APPROVAL CRITERIA
Patient must meet all of the following criteria:
I.
Patient has a diagnosis of cancer with breakthrough cancer pain AND
II.
Patient is 16 years of age or older AND
III.
Patient is already receiving opioid therapy and TOLERANT to opioid therapy, as defined
as receiving:
A.
At least 60mg morphine per day OR
B.
At least 25mcg/hr transdermal fentanyl/hour OR
C.
At least 30mg of oxycodone daily OR
D.
At least 8mg of oral hydromorphone daily OR
E.
An equianalgesic dose of another opioid for a week or longer AND
IV.
Physician has discussed the appropriate disposal of unused medication with the patient
This policy does not apply to health plans or member categories that do not have pharmacy benefits, nor
does it apply to Medicare. Note that market specific restrictions or transition-of-care benefit limitations
may apply.
PEC-ALL-1268-14-Fentanyl
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