Morphine IR Avinza, Kadian, MS Contin (Morphine sulfate ER) Dilaudid (hydromorphone IR) Exalgo (hydromorphone ER) Opana (oxymorphone IR and ER)
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1 Pre - PA Allowance Quantity Immediate-release Formulations Morphine sulfate (IR) Opana (oxymorphone) IR Dilaudid (hydromorphone) IR 360 tablets per 90 days Extended-release Formulations Avinza (morphine sulfate ER) Kadian (morphine sulfate ER) MS Contin (morphine sulfate ER) 360 tablets per 90 days Opana (oxymorphone) ER Prior-Approval Requirements Prior authorization is not required if prescribed by an oncologist Age Diagnoses 18 years of age or older Morphine Sulfate IR, Hydromorphone IR and Oxymorphone IR Patient must have the following: 1. Moderate to severe pain AND ALL of the following: a. NO dual therapy with other immediate release opioid analgesic(s) b. Alternative treatment options have been ineffective, not tolerated or inadequate for controlling the pain i. These include: non-opioid analgesics
2 c. Prescriber agrees to assess the benefits of pain control (i.e. Care Plan signs of abuse, severity of pain) after 3 months of therapy d. Prescriber agrees to assess patient for serotonin syndrome e. NO dual therapy with opioid addiction treatment f. NO dual therapy with an anti-anxiety benzodiazepine(s) i. Alprazolam (Xanax) ii. Clonazepam (Klonopin) iii. Diazepam (Valium) iv. Lorazepam (Ativan) v. Oxazepam (Serax) vi. Chlordiazepoxide (Librium) vii. Clorazepate dipotassium (Tranxene) Morphine Sulfate ER, Hydromorphone ER and Oxymorphone ER Patient must have the following: 1. Pain, severe enough to require daily, around-the clock long term opioid treatment AND ALL of the following: a. NO dual therapy with other long acting opioid analgesic(s) b. Alternative treatment options have been ineffective, not tolerated or inadequate for controlling the pain i. These include: non-opioid analgesics and immediate release analgesics c. Prescriber agrees to assess the benefits of pain control (i.e. Care Plan signs of abuse, severity of pain) after 3 months of therapy d. Prescriber agrees to assess patient for serotonin syndrome e. NO dual therapy with opioid addiction treatment f. NO dual therapy with an anti-anxiety benzodiazepine(s) i. Alprazolam (Xanax) ii. Clonazepam (Klonopin) iii. Diazepam (Valium) iv. Lorazepam (Ativan)
3 v. Oxazepam (Serax) vi. Chlordiazepoxide (Librium) vii. Clorazepate dipotassium (Tranxene) Prior - Approval Limits Quantity Immediate-release Formulations OR Morphine sulfate 15mg (IR) 900 tablets per 90 days OR Morphine sulfate 30mg (IR) 540 tablets per 90 days Maximum daily limit of any combination: 180mg Opana 5mg (Oxymorphone) (IR) 900 tablets per 90 days OR Opana 10mg (Oxymorphone) (IR) 720 tablets per 90 days OR Maximum daily limit of any combination: 80mg Dilaudid 2mg (Hydromorphone) (IR) 900 tablets per 90 days OR Dilaudid 4mg (Hydromorphone) (IR) 900 tablets per 90 days OR Dilaudid 8mg (Hydromorphone) (IR) 810 tablets per 90 days OR Maximum daily limit of any combination: 72mg Extended-release Formulations Avinza 30 mg (Morphine sulfate) 1080 capsules per 90 days OR Avinza 45 mg (Morphine sulfate) 1080 capsules per 90 days OR Avinza 60 mg (Morphine sulfate) 1080 capsules per 90 days OR Avinza 75 mg (Morphine sulfate) 1080 capsules per 90 days OR Avinza 90 mg (Morphine sulfate) 1080 capsules per 90 days OR Avinza 120 mg (Morphine sulfate) 1080 capsules per 90 days OR Maximum daily limit of any combination: 1600mg Exalgo 8mg (Hydromorphone) Exalgo 12mg (Hydromorphone) Exalgo 16mg (Hydromorphone) Exalgo 32mg (Hydromorphone) 900 tablets per 90 days OR 900 tablets per 90 days OR 720 tablets per 90 days OR 360 tablets per 90 days OR
4 Maximum daily limit of any combination: 128mg Kadian 10mg (Morphine sulfate) 900 capsules per 90 days OR Kadian 20mg (Morphine sulfate) 900 capsules per 90 days OR Kadian 30mg (Morphine sulfate) 900 capsules per 90 days OR Kadian 40mg (Morphine sulfate) 900 capsules per 90 days OR Kadian 50mg (Morphine sulfate) 900 capsules per 90 days OR Kadian 60mg (Morphine sulfate) 900 capsules per 90 days OR Kadian 80mg (Morphine sulfate) 900 capsules per 90 days OR Kadian 100mg (Morphine sulfate) 900 capsules per 90 days OR Kadian 200mg (Morphine sulfate) 540 capsules per 90 days Maximum daily limit of any combination: 1200mg MS Contin 15mg (Morphine sulfate) 900 tablets per 90 days OR MS Contin 30mg (Morphine sulfate) 900 tablets per 90 days OR MS Contin 60mg (Morphine sulfate) 900 tablets per 90 days OR MS Contin 100mg (Morphine sulfate) 900 tablets per 90 days OR MS Contin 200mg (Morphine sulfate) 540 tablets per 90 days Maximum daily limit of any combination: 1200mg Opana ER 5mg (Oxymorphone) 900 tablets per 90 days OR Opana ER 7.5mg (Oxymorphone) 900 tablets per 90 days OR Opana ER 10mg (Oxymorphone) 900 tablets per 90 days OR Opana ER 15mg (Oxymorphone) 900 tablets per 90 days OR Opana ER 20mg (Oxymorphone) 900 tablets per 90 days OR Opana ER 30mg (Oxymorphone) 540 tablets per 90 days Opana ER 40mg (Oxymorphone) 450 tablets per 90 days OR Maximum daily limit of any combination: 200mg Duration 6 months _ Prior Approval Renewal Requirements Age 18 years of age or older Diagnoses Morphine Sulfate IR, Hydromorphone IR and Oxymorphone IR
5 Patient must have the following: 1. Moderate to severe pain AND ALL of the following: a. NO dual therapy with other immediate release opioid analgesic(s) b. Prescriber agrees to assess the benefits of pain control (i.e. Care Plan signs of abuse, severity of pain) after 3 months of therapy c. Prescriber agrees to assess patient for serotonin syndrome d. NO dual therapy with opioid addiction treatment e. NO dual therapy with an anti-anxiety benzodiazepine(s) i. Alprazolam (Xanax) ii. Clonazepam (Klonopin) iii. Diazepam (Valium) iv. Lorazepam (Ativan) v. Oxazepam (Serax) vi. Chlordiazepoxide (Librium) vii. Clorazepate dipotassium (Tranxene) Morphine Sulfate ER, Hydromorphone ER and Oxymorphone ER Patient must have the following: 1. Pain, severe enough to require daily, around-the clock long term opioid treatment AND ALL of the following: a. NO dual therapy with other long acting opioid analgesic(s) b. Prescriber agrees to assess the benefits of pain control (i.e. Care Plan signs of abuse, severity of pain) after 3 months of therapy c. Prescriber agrees to assess patient for serotonin syndrome d. NO dual therapy with opioid addiction treatment
6 e. NO dual therapy with an anti-anxiety benzodiazepine(s) i. Alprazolam (Xanax) ii. Clonazepam (Klonopin) iii. Diazepam (Valium) iv. Lorazepam (Ativan) v. Oxazepam (Serax) vi. Chlordiazepoxide (Librium) vii. Clorazepate dipotassium (Tranxene) Prior Approval Renewal Limits Same as above
7 Appendix 1 - List of Serotonergic Medications Selective Serotonin Reuptake Inhibitors (SSRIs) paroxetine Paxil, Paxil CR, Pexeva, Brisdelle fluvoxamine Luvox, Luvox CR fluoxetine Prozac, Prozac Weekly, Sarafem, Selfemra, Symbyax sertraline Zoloft citalopram Celexa escitalopram Lexapro Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) venlafaxine Effexor XR desvenlafaxine Pristiq, Khedezla duloxetine Cymbalta milnacipran Savella Tricyclic Antidepressants (TCAs) amitriptyline No brand name currently marketed desipramine Norpramin clomipramine Anafranil imipramine Tofranil, Tofranil PM nortriptyline Pamelor, Aventyl protriptyline Vivactil doxepin Zonalon, Silenor trimipramine Surmontil Monoamine Oxidase Inhibitors (MAOIs) isocarboxazid Marplan phenelzine Nardil selegiline Emsam, Eldepryl, Zelapar tranylcypromine Parnate
8 Other Psychiatric Medicines amoxapine No brand name currently marketed maprotiline No brand name currently marketed nefazodone No brand name currently marketed trazodone Oleptro buspirone No brand name currently marketed vilazodone Viibryd mirtazapine Remeron, Remeron Soltab llthium Lithobid Migraine Medicines almotriptan Axert frovatriptan Frova naratriptan Amerge rizatriptan Maxalt, Maxalt-MLT sumatriptan Imitrex, Imitrex Statdose, Alsuma, Sumavel Dosepro, Zecuity, Treximet zolmitriptan Zomig, Zomig-ZMT Antiemetics ondansetron granisetron dolasetron palonosetron Zofran, Zofran ODT, Zuplenz Kytril, Sancuso Anzemet Aloxi Other Serotonergic Medicines dextromethorphan Bromfed-DM, Delsym, Mucinex DM, Nuedexta linezolid Zyvox cyclobenzaprine Amrix methylene blue St. John s wort tryptophan
12629 LIBRIUM CHLORDIAZEPOXIDE HCL 12637 LIBRIUM CHLORDIAZEPOXIDE HCL 12645 LIBRIUM CHLORDIAZEPOXIDE HCL 13110 VALIUM DIAZEPAM 13277 VALIUM DIAZEPAM 24406 LITHANE LITHIUM CARBONATE 25836 SURMONTIL TRIMIPRAMINE
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