Under some plans, including plans that use an open or closed formulary, Duragesic and fentanyl transdermal are subject to precertification.  If precertification requirements apply Aetna considers Duragesic and fentanyl transdermal to be medically necessary for those members who meet the following precertification criteria:

A.  Quantity limits:   

According to the manufacturer, one Duragesic transdermal patch and fentanyl transdermal patch will supply fentanyl for absorption for 72 hours. A quantity of Duragesic or fentanyl transdermal of up to 20 patches per 30-day increments (2 patches per 3 days) will be considered medically necessary.

For coverage of additional quantities, a member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit. Additional quantities of Duragesic or fentanyl transdermal will be considered medically necessary for those members who meet ANY of the following criteria:

• Member has diagnosis of cancer OR
• Member is enrolled in a hospice program or meets hospice criteria OR
• Duragesic prescription is written by an oncologist or pain specialist OR
• Member has a diagnosis of moderate to severe chronic pain AND
             A formal pain evaluation has been documented
             AND
             Other pain management regimens have been inadequate OR
• Member has failed an every-72-hours regimen and requires dosing every 48 hours OR
• Member requires a regimen of Duragesic or fentanyl transdermal with more than one patch every 72 hours

 

Duragesic is currently a Not Covered Part D drug under the Aetna Medicare Prescription Drug Plan.*  Therefore, it is excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Duragesic to be medically necessary for those members who meet ANY of the following criteria:

A. A documented:

• Contraindication to two covered narcotic analgesics (single entity or combination products) OR
• Intolerance to two covered narcotic analgesics (single entity or combination products) OR
• Allergy to two covered narcotic analgesics (single entity or combination products) OR
• Failure of an adequate clinical trial of one week each of at least two covered narcotic analgesics (single entity or combination products)