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  • FENTANYL OT LOZ 400MCG

    Prior Authorization only applies to members new to therapy?
    No

    Indications:
    All Part D medically-accepted Indications (FDA-approved and compendia-supported).

    Exclusion Criteria:


    Required Medical Information:
    Cancer pain: Chart documentation provided reflecting oral transmucosal fentanyl will be used to manage pain related to an active cancer diagnosis. At least a one week history of one of the following medications to demonstrate tolerance to opioids: morphine sulfate at doses of greater than or equal to 60 mg/day, fentanyl transdermal patch at doses greater than or equal to 25 ¿g/hr, oxycodone at a dose of greater than or equal to 30 mg/day , oral hydromorphone at a dose of greater than or equal to 8 mg/day, oral oxymorphone at a dose of greater than or equal to 25 mg/day, an alternative opioid at an equianalgesic dose (eg, oral methadone greater than or equal to 20 mg/day). The patient is currently taking a long-acting opioid around the clock for cancer pain

    Age Restrictions:


    Prescriber Restrictions:
    Prescribed by or in consultation with an oncologist, pain specialist, hematologist, hospice care specialist, or palliative care specialist.

    Coverage Duration:
    Plan year

    Other Criteria:


    If you are a provider, you can submit a prior authorization request online at https://professionals.optumrx.com.

    Updated: 09/2022

Last updated 10/02/2023