Under some plans, including plans that use an open or closed formulary, Actiq, butorphanol ns, Combunox, Duragesic, fentanyl patch, fentanyl transmucosal lozenge, Fentora, oxycodone/ibu and OxyContin CR, are subject to precertification. If precertification requirements apply Aetna considers Actiq, butorphanol ns, Combunox, Duragesic, fentanyl patch, fentanyl transmucosal lozenge, Fentora, oxycodone/ibu and OxyContin CR, to be medically necessary for those members who meet the following precertification criteria:

(A AND B) AND C  For Actiq, fentanyl transmucosal lozenge,  Fentora-ONLY

C - For butorphanol ns, Combunox, Duragesic, fentanyl patch, oxycodone/ibu,OxyContin CR

A documented

A. Diagnosis of cancer

AND

B. Concomitant use of long acting opioid therapy*

AND

C. According to the manufacturer and/or clinical literature, Actiq, butorphanol ns, Combunox, Duragesic, fentanyl patch, fentanyl transmucosal lozenge, Fentora,  oxycodone/ibu and OxyContin CR, can be dosed at the interval(s) indicated in the table below. A quantity of each drug will be considered medically necessary as indicated in the table below

For coverage of additional quantities, member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit.  Additional quantities of the above medications will be considered medically necessary for those members who meet the following criterion:

For Combunox, fentanyl patch, Duragesic, oxycodone/ibu, OxyContin CR,

                butorphanol

A formal pain evaluation has been documented
AND
Other pain management regimens have been inadequate OR

Member is documented to have failed dosing every 12 hours along with a prescription for immediate-release (IR) medication

AND

Member’s physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a more frequent dosing interval (OxyContin CR-only) OR

•  Member has failed an every-72-hours regimen and requires dosing every 48 hours (Duragesic, fentanyl patch-only)OR 
• Member requires a regimen of Duragesic with more than one patch every 72 hours (Duragesic, fentanyl patch-only) OR 
• Member requires a dose every 12 hours(BID) and the total daily dose is <320mg, AND the member has prior history of dose titration increasing incrementally (OxyContin CR-only) OR
• Member is documented to have failed dosing every 12 hours along with a prescription for immediate-release (IR) medication AND Member’s physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a more frequent dosing interval (OxyContin CR-only) OR
• Member’s physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose

**For fentanyl transmucosal lozenge(lpop), Actiq; Fentora

• Member has current diagnosis of cancer (as the primary cause of the pain) and is currently on long-acting opioid and  is being titrated on the long-acting opioid by physician
  AND
• Member has tried and failed an adequate trial of two weeks of a single entity or combination pain medication containing an immediate release acting opioid (ex. oxycodone, morphine sulfate oral(Roxanol); oxymorphone(Opana); hydromorphone(Dilaudid); oxycodone/ibuprofen(Combunox); oxycodone/apap(Percocet))
  

Alcet, Anexsia, Bancap HC Capital/Codeine, Combunox, Darvocet-N, Darvon, Darvon Compound, Duragesic, Fioricet/Codeine, Fiorinal/Codeine, Fentora, Lorcet/HD/Plus, Lortab, Lortab elixir, Lynox, Magnacet, Maxidone,  Norco,  Percodan, Percocet, Percocet 2.5/325, Reprexain, Roxicet, Roxicet 5/500, Synalgos DC, Talacen, Tylenol #3, Tylox, Trycet, Ultram, Ultram ER, Vicodin, Vicodin ES, Vicoprofen, Vopac,  Xodol, and Zydone are currently listed on the Step-Therapy List.* Therefore, these are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step-therapy criteria, unless a medical exception is granted.  Aetna considers them to be medically necessary for those members who meet the criteria below:

For Alcet, Anexsia, Bancap HC Capital/Codeine, Darvocet-N, Darvon, Darvon Compound, Duragesic, Fioricet/Codeine, Fiorinal/Codeine, Fentora, Lorcet/HD/Plus, Lortab, Lortab elixir, Maxidone,  Norco, Percodan, Percocet, Roxicet, Talacen, Tylenol #3, Tylox, Trycet, Ultram, Vicodin, Vicodin ES, and Vicoprofen

A.  A documented:

• Contraindication to the preferred generic equivalent alternative OR
• Intolerance to the preferred generic equivalent alternative OR
• Allergy to the preferred generic equivalent alternative OR
• Failure of an adequate clinical trial of two days of the preferred generic equivalent alternative.

For Combunox, Fentora, Lynox, Magnacet, Percocet 2.5/325, Reprexain, Roxicet 5/500, Synalgos DC, Ultram ER, Vopac, Zydone tab, and Xodol

For Combunox
A.  A documented:

• Contraindication to a  preferred generic oxycodone combination alternative OR
• Intolerance to a preferred generic oxycodone combination alternative OR
• Allergy to a preferred generic oxycodone combination alternative OR 
• Failure of an adequate clinical trial of two days of a preferred generic oxycodone combination alternative

For Fentora
A.  A documented:

• Contraindication to the preferred generic fentanyl transmucosal lozenge   alternative OR
• Intolerance to the preferred generic fentanyl transmucosal lozenge   alternative OR
• Allergy to the preferred generic fentanyl transmucosal lozenge   alternative OR
• Failure of an adequate clinical trial of one week of the preferred generic fentanyl transmucosal lozenge alternative

For  Lynox, Magnacet, Percocet 2.5/325, Roxicet 5/500
A.  A documented:

• Contraindication to a preferred generic oxycodone/acetaminophen combination alternative OR
• Intolerance to a preferred generic oxycodone/acetaminophen combination alternative OR
• Allergy to a preferred generic oxycodone/acetaminophen combination alternative OR
• Failure of an adequate clinical trial of two days of a preferred generic oxycodone/acetaminophen combination alternative.

For Reprexain
A.  A documented: 

• Contraindication to a preferred generic hydrocodone/ibuprofen combination alternative OR
• Intolerance to a preferred generic hydrocodone/ibuprofen combination alternative OR
• Allergy to a preferred generic hydrocodone/ibuprofen combination alternative OR
• Failure of an adequate clinical trial of two days of a preferred generic hydrocodone/ibuprofen combination alternative

For Synalgos DC
A.  A documented: 

• Contraindication to a preferred generic dihydrocodeine combination alternative OR
• Intolerance to a preferred generic dihydrocodeine combination alternative OR
• Allergy to a preferred generic dihydrocodeine combination alternative OR
• Failure of an adequate clinical trial of two days of a preferred generic dihydrocodeine combination alternative

For Ultram ER
A. A documented:

• Contraindication to a preferred generic tramadol alternative OR
• Intolerance to a preferred generic tramadol alternative OR 
• Allergy to a preferred generic tramadol alternative OR
• Failure of an adequate clinical trial of two days of a preferred generic tramadol alternative

For Vopac,
A. A documented:

• Contraindication to a preferred generic acetaminophen/codeine combination alternative OR 
• Intolerance to a preferred generic acetaminophen/codeine combination alternative OR
• Allergy to a preferred generic acetaminophen/codeine combination alternative OR
• Failure of an adequate clinical trial of two days of a preferred generic acetaminophen/codeine combination alternative

For Xodol and Zydone
A. A documented:

• Contraindication to a preferred generic hydrocodone/acetaminophen combination alternative OR 
• Intolerance to a preferred generic hydrocodone/acetaminophen combination alternative OR 
• Allergy to a preferred generic hydrocodone/acetaminophen combination alternative OR
• Failure of an adequate clinical trial of two days of a preferred generic hydrocodone/acetaminophen combination alternative
   

Alcet, Anexsia, Bancap HC Capital/Codeine, Combunox, Darvocet-N, Darvon, Darvon Compound, Duragesic, Fioricet/Codeine, Fiorinal/Codeine, Fentora, Lorcet/HD/Plus, Lortab, Lortab elixir, Lynox, Magnacet, Maxidone,  Norco,  Percodan, Percocet, Percocet 2.5/325, Reprexain, Roxicet, Roxicet 5/500, Synalgos DC, Talacen, Tylenol #3, Tylox, Trycet, Ultram, Ultram ER, Vicodin, Vicodin ES, Vicoprofen, Vopac,  Xodol, and Zydone are currently listed on the Step-Therapy List.* Therefore, these are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step-therapy criteria, unless a medical exception is granted.  Aetna considers them to be medically necessary for those members who meet the criteria below:

For Alcet, Anexsia, Bancap HC Capital/Codeine, Darvocet-N, Darvon, Darvon Compound, Duragesic, Fioricet/Codeine, Fiorinal/Codeine, Fentora, Lorcet/HD/Plus, Lortab, Lortab elixir, Maxidone,  Norco, Percodan, Percocet, Roxicet, Talacen, Tylenol #3, Tylox, Trycet, Ultram, Vicodin, Vicodin ES, and Vicoprofen

A.  A documented:

• Contraindication to the preferred generic equivalent alternative OR
• Intolerance to the preferred generic equivalent alternative OR
• Allergy to the preferred generic equivalent alternative OR
• Failure of an adequate clinical trial of two days of the preferred generic equivalent alternative.

For Combunox, Fentora, Lynox, Magnacet, Percocet 2.5/325, Reprexain, Roxicet 5/500, Synalgos DC, Ultra