Subject: Symproic PA Policy 1713-A UDR 10-2023

Drug

SYMPROIC  (naldemedine)

Policy:

FDA-APPROVED INDICATIONS          
Symproic is indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation.


COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
     •   The requested drug is being prescribed for the treatment of
          opioid-induced constipation (OIC) in an adult patient with
          chronic non-cancer pain, including chronic pain related to prior
          cancer or its treatment who does not require frequent (e.g.,
          weekly) opioid dosage escalation

Duration of Approval (DOA):
     •   1713-A: DOA: 12 months

 

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Symproic [package insert]. Raleigh, NC: BioDelivery Sciences International, Inc.; July 2021.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Waltham, MA: UpToDate, Inc.; 2023. https://online.lexi.com. Accessed July 25, 2023.
3. Micromedex (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 07/25/2023).

 

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

February 11, 2024