Prior Auth Protocol

FDA Approved Indications:

Varies by drug product

Health Net Approved Indications and Usage Guidelines:

Diagnosis of cancer pain

OR

End-stage medical conditions accompanied by significant pain

OR

Pain for which there is a documented, objective etiology

AND

Documentation that the patient is being managed under a pain medication contract signed by both the provider and the patient individually and dated within the year

OR

Patient resides in a Skilled Nursing Facility (SNF) or Long Term Care (LTC) facility

AND

For a non-formulary drug, failure or clinically significant adverse effect to two or more formulary alternatives (or one if only one is available) that are FDA approved or standard pharmacopeias (e.g., DrugDex) support efficacy and safety for the requested indication

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.

General Information:

Health Net Medi-Cal's narcotic quantity limits closely mirror those of the Department of Health Care Services (DHCS) pharmacy benefit.

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
This field intentionally left blank.	This field intentionally left blank.	This field intentionally left blank.

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Various Narcotics	Various	Cancer pain: Length of Benefit End-stage medical conditions accompanied by significant pain: Length of benefit SNF or LTC Facility Residence: Length of Benefit All other diagnoses: Initial authorization: Up to 1 year Re-authorization: A new pain medication contract is required every year. Up to 1 year

Product Availability:

This field intentionally left blank.

References:

1. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain 6th Edition; American Pain Society 2008.
2. 2015 National Drug Control Strategy, Office of National Drug Control Policy. Available at https://www.whitehouse.gov//sites/default/files/ondcp/policy-and-research/2015_national_drug_control_strategy_0.pdf. Accessed July 2016.