Prior Auth Protocol

FDA Approved Indications:

Management of moderate to severe pain when continuous, around-the-clock analgesia is needed for an extended period of time

Health Net Approved Indications and Usage Guidelines:

Chronic pain for which there is a documented, objective etiology

AND

Failure or clinically significant adverse effects to TWO formulary controlled-release products: controlled-release morphine sulfate, Avinza^R, sustained-release morphine sulfate, fentanyl patch or extended-release oxymorphone. (This applies to new starts only).

AND

A treatment plan is required, including:
- Diagnosis or conditions that are contributing to the 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

Coverage is Not Authorized For:

Acute or intermittent pain
Immediate post-surgical pain
Use in patients who require opioid analgesia for a short period of time
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:

Avinza^R (45 mg, 60 mg, 75 mg, 90 mg and 120 mg), Kadian^R (100 mg and 200 mg), MS Contin^R (100 mg and 200 mg), OxyContin (60 mg; and 80 mg, a single dose greater than 40 mg, or a total daily dose greater than 80 mg) and Duragesic^R are for use only in opioid tolerant patients.
Because it may be difficult to determine analgesic need using a controlled-release product, it is recommended to initiate therapy with immediate-release products. The table below may be useful in determining the appropriate dosing of a variety of analgesic options.

EQUIANALGESIC OPIOID CHART
Analgesic	Parenteral IM, SC, IV (mg)	Oral/Rectal/Patch (mg)
Morphine*	10	30
Codeine	130	200
Fentanyl	0.1 to 0.2	25 mcg/hr (Patch)
Hydromorphone	1.5	7.5
Levorphanol	2	4
Methadone	10	20
Meperidine*	75	-
Oxycodone	-	20
Oxymorphone	1	10 (Rectal)

*Adjust dose in renal impairment

Due to the potency of OxyContin, it is recommended to use the conversion factor table when converting TO oral oxycodone to avoid overestimating the dose.
Conversion back FROM prior opioid divides by the conversion factor shown in the table below.

Estimated conversion factor for converting prior opioid doses to oral oxycodone² (mg/day prior opioid x factor = mg/day oral oxycodone
Prior Opioid	Oral	Parenteral
Codeine	0.15	--
Hydrocodone	0.9	--
Hydromorphone	4	20
Levorphanol	7.55	15
Meperidine	0.1	0.4
Methadone	1.5	3
Morphine	0.5	1.5 - 3
Oxycodone	1	--
Oxymorphone	2	--

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
morphine sulfate controlled-release tablet (MS Contin^R )	Conversion to MS Contin^R Dosing is individualized based on previous analgesic therapy. Administer at = the total daily requirement PO Q12 hours or 1/3 the total daily requirement PO Q8 hours	The 100 mg and 200 mg tablets are reserved only for opioid-tolerant individuals who require morphine equivalent doses of 200 mg or more for the 100 mg tablet and 400 mg or more for the 200 mg tablet
morphine sulfate sustained-release (Kadian^R)	Opioid naive patients 10 mg or 20 mg PO, may adjust dosage at 20 mg increment QOD Conversion to Kadian^R Dosing is individualized based on previous analgesic therapy. Administer patient's total daily requirement PO Q24 hours or Q12 hours at = the estimated total daily requirement	Should not be given more frequently than every 12 hours
Fentanyl transdermal system (Duragesic^R )	Dosing is individualized based on previous analgesic therapy. Initiate dose at one patch TD every 72 hours. May increase following 3 days of therapy. Some patients may require dosing every 48 hours.	Doses > 25 mcg/hr patch are reserved for opioid-tolerant individuals.
Avinza^R	Opioid naive patients 30 mg PO Q24 hours, with dosage adjustments of not > 30 mg every 4 days Conversion to Avinza^R Dosing is individualized based on previous analgesic therapy. Administer patient's total daily morphine requirement PO Q24 hours.	1600 mg/day Should not be given more frequently than every 24 hours
Extended-release oxymorphone (Opana ER^R)	One tablet PO BID; individualized dosing may require multiple tablets dosing	Patients who are not opiod-experienced being initiated on chronic around-the-clock opiod therapy be started with Opana ER 5 mg every 12 hours

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Controlled-release oxycodone (OxyContin)	One tablet PO BID; individualized dosing may require multiple tablets and TID dosing	3 months initially for non-malignant pain. Treatment plan may be required for continued authorization. 1 year for cancer patients

Product Availability:

Oxycontin tablet: 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

References:

Avinza^R [Prescribing Information] Bristol, TN: King Pharmaceuticals, Inc.; April 2008.
Opana ER^R [Prescribing Information] Chadds Ford, PA: Endo Pharmaceuticals, Inc.;January 2012.
OxyContin^R [Prescribing Information] Stamford, CT: Purdue Pharma; April 2013.
MS Contin^R [Prescribing Information] Stamford, CT: Purdue Pharma; March 2009.
Kadian^R [Prescribing Information] Morristown, NJ: Actavis; February 2010.
Duragesic^R [Prescribing Information] Raritan, NJ: PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.;October 2011.
Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain 6^th Edition; American Pain Society 2008.
DRUGDEX^R System [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed June 14, 2013.
American Hospital Formulary Service Drug Information. AHFSWeb site. Available at: http://http://www.medicinescomplete.com/mc/ahfs/current/. Accessed June 14, 2013.