Diagnosis of Type 2 diabetes Indefinite Trial and failure of metformin in combination with Januvia or Byetta for at least 3 consecutive months OR Trial and failure of Janumet for at least 3 consecutive months Age restriction: must be at 18 years old Long acting Opioids STEP criteria for Oxymorphone ER: Initial Approval: Oxycontin Treatment of chronic pain 1 year Butrans Patch At least 18 years old Exalgo Failed a minimum of 2 week trials of maximum tolerated doses of at least TWO formulary Renewal: Oxymorphone ER long-acting opioids (i.e., fentanyl patch, morphine sulfate ER, methadone) OR have 1 year Zohydro ER contraindications to all formulary agents. Xartemis XR Nucynta ER) Criteria for Oxycontin and other Non-Formulary Long-Acting Opioids: Treatment of malignant pain and pain due to sickle cell anemia (Oxycontin) OR Treatment of chronic non-malignant pain: At least 18 years old Failed a minimum of 2 week trials of maximum tolerated of at least THREE formulary long-acting agents (i.e., fentanyl patch, morphine sulfate ER, methadone, oxymorphone ER) one of which must be oxymorphone ER OR Contraindication to all formulary long-acting agents OR Treatment of diabetic peripheral neuropathy (Nucynta ER only): At least 18 years old Failed an adequate trial (at least 4 weeks at maximum tolerated doses) of duloxetine and tramadol and at least ONE additional formulary medication (i.e., gabapentin, amitriptyline, nortriptyline, or topical capsaicin) OR Contraindications to all formulary agents
Diagnosis of Type 2 diabetes Trial and failure of metformin in combination with Januvia or Byetta for at least 3 consecutive months OR Trial and failure of Janumet for at least 3 consecutive months Age restriction: must be at 18 years old Indefinite Long acting Opioids Oxycontin Butrans Patch Exalgo Oxymorphone ER Zohydro ER Xartemis XR Nucynta ER) STEP criteria for Oxymorphone ER: Treatment of chronic pain At least 18 years old Failed a minimum of 2 week trials of maximum tolerated doses of at least TWO formulary long-acting opioids (i.e., fentanyl patch, morphine sulfate ER, methadone) OR have contraindications to all formulary agents. Criteria for Oxycontin and other Non-Formulary Long-Acting Opioids: Treatment of malignant pain and pain due to sickle cell anemia (Oxycontin) OR Treatment of chronic non-malignant pain: At least 18 years old Failed a minimum of 2 week trials of maximum tolerated of at least THREE formulary long-acting agents (i.e., fentanyl patch, morphine sulfate ER, methadone, oxymorphone ER) one of which must be oxymorphone ER OR Contraindication to all formulary long-acting agents OR Treatment of diabetic peripheral neuropathy (Nucynta ER only): At least 18 years old Failed an adequate trial (at least 4 weeks at maximum tolerated doses) of duloxetine and tramadol and at least ONE additional formulary medication (i.e., gabapentin, amitriptyline, nortriptyline, or topical capsaicin) OR Contraindications to all formulary agents Initial Approval: 1 year Renewal: 1 year
MMIC-PA-SMI-Guidelines.docx