Prior Authorization Protocol - Health Net

Prior Authorization Protocol ACTIQ , FENTORA (oral transmucosal fentanyl citrate [OTFC]), ABSTRAL (fentanyl sublingual), LAZANDA™ (fentanyl nasal spray), SUBSYS™ (fentanyl sublingual spray) 

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NATL Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document I. FDA Approved Indications: •

The management of breakthrough pain in cancer patients (≥16 years old for Actiq and ≥ 18 years old for Fentora, Lazanda, Subsys and Abstral) who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain.

II. Health Net Approved Indications and Usage Guidelines: •

Diagnosis of cancer AND

•

Member is on fentanyl transdermal patches AND

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For Abstral, Fentora, Lazanda and Subsys requests: Failure or clinically significant adverse effects to generic fentanyl citrate oral transmucosal lozenge (Actiq) 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

III. 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.

Draft Approved: Clinical Pharmacy Advisory Committee Approved by: Health Net Pharmacy & Therapeutics Committee: 11.16.05, 5.16.07, 06.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14 Updated: 07.31.2003, 05.20.05 SB, 10.25.05 RJL, 02.02.06 RJL, 03.03.06 CM, 12.06.06CM, 12.11.06 SB, 01.02.08 A Manoucheri, 06.26.08 J.Johnson, 07.30.09 J.Johnson, 09.20.09 J.Johnson, 07.30.10 J.Johnson, 5.18.11 S Redline, 5.31.11 T Lee, 10.13.11MJMcClusky, 01.10.12 MJMcClusky, 06.18.12 S Tabarangao, 06.26.13 CMisquitta, 04.10.14 R. Olegario, 06.26.14 MJMcClusky, 10.17.14 CMisquitta, 10.28.14 . Gedey, 06.22.15, HTan, 12.13.16 M Del Nero Page 1


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NATL IV. General Information: •

•

•

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Because of the potential risk for misuse, abuse, and overdose, the fentanyl sublingual and transmucosal products listed below are only available through restricted distribution programs. Under the transmucosal immediate release fentanyl risk evaluation and mitigation strategy (TIRF REMS) program, only prescribers, pharmacies, and patients registered with TIRF REMS are able to prescribe, dispense, and receive these products. Additional information is available at: www.tirfremsaccess.com/TirfUISplashWeb/index.html or by calling 1-866-822-1483. These products are not interchangeable and must not be used in opioid non-tolerant patients because life-threatening hypoventilation could occur at any dose in patients not taking chronic opiates. Substantial differences exist in the pharmacokinetic profiles of these drugs that result in clinically important differences in the extent of absorption of fentanyl. As a result of these differences, the substitution of these products may result in fatal overdose. Patients considered opioid tolerant are those who are taking around the clock medicine consisting of at least 60 mg morphine/day, at least 25mcg transdermal fentanyl/hour, at least 30 mg of oxycodone daily, at least 8 mg oral hydromorphone daily, or an equianalgesic dose of another opioid for a week or longer. Fentanyl absorption with different formulations of transmucosal delivery systems can be substantially different. When Abstral is prescribed, patients should not be converted on a mcg per mcg basis from any other oral transmucocal fentanyl product. Patients beginning treatment with Abstral must begin with titration from 100 mcg dose. Patients switching from Actiq to Fentora should be initiated as shown: Actiq dose (mcg) 200 400 600 800 1200 1600

V.

Fentora dose (mcg) 100 100 200 200 400 400

Therapeutic Alternatives: Drug morphine sulfate immediate release oxycodone immediate release (Roxicodone) hydromorphone (Dilaudid)

Dosing Regimen 10 mg –30 mg PO Q 4 H PRN Individualize dosage based on extent of preexisting opioid tolerance 5 mg - 15 mg PO Q 4 to 6 H PRN Individualize dosage based on extent of preexisting opioid tolerance 2 mg – 4 mg PO Q 3 to 4 H PRN Individualize dosage based on extent of preexisting opioid tolerance

Dose Limit/Maximum Dose Varies

Varies

Varies



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NATL VI.

Recommended Dosing Regimen and Authorization Limit: Drug Actiq

Fentora

Abstral

Lazanda

Dosing Regimen Initiate dosing with 200 mcg PO and if breakthrough episode is not relieved in 30 minutes, patients may take only 1 additional dose using the same strength and must wait at least 4 hours before taking another dose. Individually titrate to a dose that provides adequate analgesia using single dosage unit per breakthrough cancer pain episode and minimizes side effects. Initial prescription recommendation for maximum of 6 units; No more than 4 doses per day; separate by at least 4 hours. Initiate dosing with 100 mcg PO and if breakthrough episode is not relieved in 30 minutes, patients may take only 1 additional dose using the same strength and must wait at least 4 hours before taking another dose.

Begin titration of all patients with an initial dose of Abstral of 100 mcg SL. Due to differences in the pharmacokinetic properties and individual variability, even patients switching from other fentanyl containing products to Abstral must start with the 100 mcg dose. Abstral is not equivalent on a mcg per mcg basis with all other fentanyl products, therefore, do not switch patients on a mcg per mcg basis from any other fentanyl product. The safety and efficacy of doses higher than 800 mcg have not been evaluated. Initial dose of Lazanda for all patients is 100 mcg. Individually titrate to an effective dose, from 100 mcg to 200 mcg to 400 mcg, and up to a maximum of 800 mcg, that provides adequate analgesia with tolerable side effects.

Authorization Limit Length of benefit Maximum 90 lozenges per 30 days - - Use of more than 3 lozenges/buccal films/tablets per day indicates the need to increase the dose of fentanyl transdermal patches

Length of benefit Maximum 90 tablets per 30 days - Use of more than 3 lozenges/buccal films/tablets per day indicates the need to increase the dose of fentanyl transdermal patches Length of benefit Maximum 90 tablets per 30 days - Use of more than 3 lozenges/buccal films/tablets per day indicates the need to increase the dose of fentanyl transdermal patches

Length of benefit Maximum 96 sprays (12 bottles) per 30 days - Use of more indicates the need



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NATL Drug

Subsys

VII.

Authorization Limit to increase the dose of fentanyl transdermal patches

Length of benefit Maximum 90 sprays per 30 days - Use of more indicates the need to increase the dose of fentanyl transdermal patches

Product Availability: • •

• • VIII.

Dosing Regimen Dose is a single spray into one nostril or a single spray into each nostril (2 sprays). Maximum dose is a single spray into one nostril or single spray into each nostril per episode; no more than four doses per 24 hours. Wait at least 2 hours before treating another episode of breakthrough pain with Lazanda. Initial dose of Subsys: 100 mcg. Individually titrate to a tolerable dose that provides adequate analgesia using a single Subsys dose per breakthrough cancer pain episode. No more than two doses can be taken per breakthrough pain episode. Wait at least 4 hours before treating another episode of breakthrough pain with Subsys. Limit consumption to four or fewer doses per day once successful dose is found.

Actiq (oral transmucosal fentanyl): available as 200 mcg, 400 mcg, 600 mcg, 800 mcg,1200 mcg and 1600 mcg lozenges. 30 lozenges per package. Fentora (fentanyl buccal tablet): available as 100 mcg, 200 mcg, 400 mcg, 600 mcg, and 800 mcg buccal tablets. Package of 7 blister cards containing 4 tablets in each card. Abstral (fentanyl sublingual tablet); available in 100 mcg, 200 mcg, 300 mcg, 400 mcg (12 or 32 tablets per package), 600 mcg, and 800 mcg (32 tablets per package) sublingual tablets. Lazanda (metered dose nasal spray): available as 100 mcg or 400 mcg per spray. Each bottle contains 8 sprays. Subsys single spray units of 100 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1200 mcg, and 1600 mcg per spray

References: 1. Actiq [Prescribing Information]. Salt Lake City, UT: Cephalon, Inc; April 2014. 2. Aronoff GM, Brennan MJ, Pritchard DD, Ginsberg B. Evidence-based oral transmucosal fentanyl citrate (OTFC) dosing guidelines. Pain Medicine. 2005,6(4):305-14. 3. Fentora [Prescribing Information]. Salt Lake City, UT: Cephalon, Inc; November 2013. 4. Micromedex® Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed June 03, 2015. 5. Fentanyl. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed June 26, 2014



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NATL 6. Abstral [Prescribing Information]. Bedminster, NJ: ProStrakken. November 2014. 7. Lazanda [Prescribing Information] Bedminster, New Jersey; Arcjimedes Pharmaceuticals; March 2015. 8. Subsys [Prescribing Information] Phoenix, AZ; Insys Therapeutics, December 2014.

The materials provided to you are guidelines used by this health plan to authorize, modify, or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual needs and the benefits covered under your contract.


Prior Authorization Protocol - Health Net

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