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Three Drugs added to Prior Review list as of July 1

Effective July 1, 2009, prior review is required for coverage of alefacept injection (Amevive) and for transmucosal fentanyl (Actiq, Fentora).

In order to request coverage for Amevive or for transmucosal fentanyl, providers must complete and fax the appropriate prior review fax form to BCBSNC. The form can be downloaded from our Web site at www.bcbsnc.com via the Provider portal.

Amevive

Criteria for coverage of Amevive are outlined in a new medical policy that is available online in the "Medical Policy" section. The patient must have moderate to severe plaque psoriasis, be at least 18 years of age, have received phototherapy (or is not a candidate for phototherapy), and have received other systemic treatments for psoriasis before coverage for Amevive will be considered. Please see the medical policy for more detail. If approved, Amevive is covered under BCBSNC's medical benefits.

Transmucosal Fentanyl

Transmucosal fentanyl formulations will also require prior review for coverage. Drug products containing fentanyl designed to be absorbed through the buccal mucosa include fentanyl citrate lozenges (Actiq and generics) and fentanyl buccal tablets (Fentora).

There is no specific medical policy on the use of this drug as the criteria for coverage of transmucosal fentanyl follows FDA-approved indications:

  1. Patients must have breakthrough pain due to cancer.
  2. Patients must be receiving chronic opioid therapy, preferably with a long-acting opioid formulation.
  3. Patients are considered opioid tolerant when any of the following doses are used, for one week or longer:
    • at least 60 mg morphine/day
    • at least 25 mcg transdermal fentanyl/hour
    • at least 30 mg of oxycodone daily
    • at least 8 mg oral hydromorphone daily
    • an equianalgesic dose of another opioid
  4. Patients must be 16 years of age or older.
  5. When patients are able to take other oral immediate-release opioids for management of breakthrough pain, at least one other short-acting, immediate-release opioid must have been tried and failed or not tolerated.
  6. Use of fentanyl is contraindicated for:
    • treatment of acute or postoperative pain
    • patients who are not taking chronic opiates
    • patients who are not opioid-tolerant
    • patients with hypoxia or hypercarbia
  7. The quantity requested cannot exceed four (4) units per day (120 lozenges or tablets per 30 days or less). For patients who are still in the titration process of determining their effective dose, larger quantities of up to 180 units per 30 days may be approved.

Fentanyl citrate lozenges (Actiq and generics) and fentanyl buccal tablets (Fentora) are covered under BCBSNC's pharmacy benefits.