CurrentColorado Rocky Mountain Health PlansPolicy N/A

Transmucosal Fentanyl Prior Authorization Request (Washington)

This form governs prior authorization requests for transmucosal fentanyl products for members in Washington and documents clinical information, prior trials, and criteria for approval, primarily for cancer-related breakthrough pain. It affects prescribing providers and pharmacies processing authorization for Colorado Rocky Mountain Health Plans members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTransmucosal Fentanyl Prior Authorization Request (Washington)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with confirmation of cancer diagnosis, documentation that transmucosal fentanyl is for breakthrough cancer pain, evidence of opioid tolerance (≥60 MME/day), prior trials of two immediate‑release opioids, and required provider signature and documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24+ hrsallow at least time for review

fax: 866-940-7328submission fax number

phone: 800-310-6826questions/assistance phone

requiredcancer diagnosis queried on form

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Coverage Criteria

Initial and continuation therapy criteria

Covered when ALL of the following are met

Primary criteria: Patient has a confirmed diagnosis of cancer; transmucosal fentanyl is prescribed for breakthrough cancer pain; patient is opioid-tolerant as demonstrated by at least 60 MME/day of chronic long-acting opioids or meets specified expedited/approved dose pathways; provider documents failure of two oral immediate-release opioids (e.g., morphine, hydromorphone, oxycodone) and completes prior medication trials section; requested medication is prescribed by or in consultation with a specialist in oncology or pain management related to oncology; continuation requests include confirmation that cancer-related pain is controlled and appropriately titrated to minimize use of transmucosal fentanyl products.see node text

Form details dose-handling: doses <120 MME approved through cancer-pain expedited authorization; 120–200 MME require Opioid High Dose form; >200 MME require an existing approved prior authorization.

This prior authorization form is not intended for non‑cancer pain. Specifically, use of transmucosal fentanyl for management of acute or postoperative pain not related to cancer treatment, headache/migraine, dental pain, or emergency room pain is excluded from appropriate use and will not meet coverage criteria under this form.

Requests for transmucosal fentanyl will not be approvable under this form for patients who are currently non‑tolerant to opioids or who are not on a long‑acting opioid for treatment of cancer pain. The form requires documentation that the patient is opioid‑tolerant at a threshold of >= 60 MME per day of chronic long‑acting opioids or meets the specified authorization pathways for higher doses.

Coding and Clinical Thresholds

Diagnosis codes requestedICD-10

ICD-10

ICD-10 CODE (member diagnosis to be provided)

Opioid tolerance MME — >= 60 MME per day

Opioid tolerance threshold>= 60 MME per day

Documentation optionsForm asks to indicate tolerance as demonstrated by at least 60 MME/day of chronic long-acting opioids

Dose-handling notesDoses <120 MME approved through cancer-pain expedited authorization; 120–200 MME require Opioid High Dose form; >200 MME require existing approved prior authorization

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required. Transmucosal fentanyl products for breakthrough cancer pain require a completed prior authorization confirming cancer diagnosis and that the drug is being used specifically for breakthrough cancer pain. Include documentation that the member is opioid-tolerant per policy thresholds, current around-the-clock long-acting opioid regimen if applicable, and whether the patient is enrolled in hospice.

Confirm diagnosis of cancer (checkbox in All Requests).
Document that transmucosal fentanyl is for treatment of breakthrough cancer pain (All Requests).
Document current around-the-clock long-acting opioid therapy for persistent cancer pain, listing medication(s) as applicable (All Requests).
Opioid tolerance documentation: patient tolerant on at least 60 MME/day or meet expedited authorization/high-dose requirements (doses <120 MME, 120–200 MME require Opioid High Dose form, >200 MME require prior authorization on file).
Specify prescriber specialty: prescribed by or in consultation with oncology or pain management related to oncology.

Step Therapy

Conservative Treatment Requirements

Definitions

Opioid tolerant — definition used on the form

Form definition of opioid-tolerantAt least 60 MME per day of chronic long-acting opioids or meeting specified authorization pathways

Assessment on formCheckbox asks whether patient is tolerant on at least 60 MME per day and to indicate which condition applies

Related provider actionTolerance documentation is required for prior authorization of transmucosal fentanyl for breakthrough cancer pain

Breakthrough cancer pain — definition used on the form

Form definition of breakthrough cancer painAcute episodes of pain treated with transmucosal fentanyl in patients using around-the-clock long-acting opioids for persistent cancer pain

Form questionIs the patient using transmucosal fentanyl for the treatment of breakthrough cancer pain? (Yes/No)

Background

Transmucosal fentanyl products are indicated and managed through this form for breakthrough cancer pain in patients who are opioid‑tolerant. The form focuses the policy on confirming a diagnosis of cancer, verifying the medication is being used specifically for breakthrough cancer pain, and documenting opioid tolerance (including the explicit >= 60 MME per day threshold and the documented handling of doses <120 MME, 120–200 MME, and >200 MME). It also requires evidence of failure of two oral immediate‑release opioids and that the prescriber is a specialist in oncology or pain management or is consulting with one.

Not Covered

The form explicitly excludes coverage for use of transmucosal fentanyl for acute or postoperative non‑cancer pain, as well as for headache/migraine, dental pain, or pain treated in an emergency room. These situations are not considered appropriate indications for transmucosal fentanyl under this policy.