Fentanyl Oral Prior Authorization (with Quantity Limit) Criteria – Medicare Part D

Fentanyl citrate lozenge (lollipop) will be approved when ALL of the following are met:

1. ONE of the following: 
   1. The patient has a documented diagnosis (i.e. medical records) of chronic cancer pain due to an active malignancy AND BOTH of the following: 
      1. The prescriber has provided the patient’s type of cancer AND 
      2. The patient is at least 16 years of age AND 
      3. There is evidence of a claim that the patient is currently being treated with a longacting opioid with the requested medication OR 
   2. The patient has a diagnosis that is supported in CMS approved compendia for the requested medication AND 
2. The patient will NOT be using the requested medication in combination with any other oral or nasal fentanyl medication AND 
3. ONE of the following: 
   1. The requested quantity (dose) does NOT exceed the program quantity limit OR 
   2. The requested quantity (dose) is greater than the program quantity limit AND BOTH of the following: 
      1. Episodes of breakthrough pain cannot be controlled by modifying the long-acting opioid dosage AND 
      2. The prescriber has provided information in support of therapy with a higher quantity (dose) for the requested indication

Length of Approval: 12 months