Transcription of Division: Pharmacy Policy Subject: Prior Authorization ...
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Division: Pharmacy Policy Subject: Prior Authorization ...
Division: Pharmacy Policy Subject: Prior Authorization Criteria Original Development Date: Original Effective Date: Revision Date: December 21, 2015 January 15, 2016, March 12, 2018 1 of 2 | P a g e METHADONE LENGTH OF Authorization : UP TO 3 MONTHS INITIAL REVIEW CRITERIA: Patient is > 18 years old AND Patient is prescribed methadone for the treatment of severe, chronic pain and is NOT being treated with methadone for the management of opioid addiction AND Methadone is prescribed on a scheduled basis (not as needed ) AND The plan is to discontinue all other long acting opioids upon initiation of therapy with methadone AND The patient has a diagnosis of metastatic cancer OR The patient has a diagnosis of any non-metastatic cancer or chronic
Division: Pharmacy Policy Subject: Prior Authorization Criteria Original Development Date: Original Effective Date: Revision Date: December 21, 2015 January 15, 2016, March 12, 2018
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