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Prior Authorization Protocol

Coverage of drugs is first determined by the memberís pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.
  1. FDA Approved Indications:
    Varies by drug product
  2. Health Net Approved Indications and Usage Guidelines:
    • Requests, for quantities of narcotics which exceed the limits set by Health Net, must include a treatment plan containing all of the following:
      • Diagnosis or conditions that are contributing to the pain (specify whether the patient has cancer pain, resides in a long-term care facility or has an end-stage medical condition accompanied by pain)
      • Pain intensity (scales or ratings)
      • Functional status (physical and psychosocial)
      • Patient`s goal of therapy (level of pain acceptable and/or functional status)
      • Current analgesic (opioid and adjuvant) regimen
      • Current non-pharmacological treatment
      • Opioid-related side effects
      • Indications of medical misuse
      • Action plan if analgesic failure occurs
    • Patient must be titrated up from the lower dose with partial improvement and without adverse reactions
  3. Coverage is Not Authorized For:
    • Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
  4. General Information:
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  5. Therapeutic Alternatives:
    Drug Dosing Regimen Dose Limit/ Maximum Dose
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    * Requires Prior Authorization
  6. Recommended Dosing Regimen and Authorization Limit:
    Drug Dosing Regimen Authorization Limit

    Various narcotics


    Cancer Pain
    Length of Benefit
    End-stage medical conditions accompanied by significant pain
    Length of Benefit
    LTC Facility Resident
    Length of Benefit
    All other diagnoses
    6 months initially for non-malignant pain.
    Duration of re-authorization may be for up to one year upon submitting written documentation of a current treatment plan.
  7. Product Availability:
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  8. References:
    1. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain 6th Edition; American Pain Society 2008.
    2. DRUGDEXR System [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed June 25, 2014.
    3. American Hospital Formulary Service Drug Information. AHFSWeb site. Available at: http:// Accessed June 25, 2014.
The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.