Oxycodone Hydrochloride Generic Roxicodone 30mg M30 1 Pill Delivery From Philippines

Description

OXYCODONE HCL CONTROLLED-RELEASE TABLETS (OxyContin®)
UTILIZATION MANAGEMENT CRITERIA

DRUG CLASS: Opioid analgesic

BRAND (generic) NAMES: OxyContin (oxycodone HCL controlled-release) Tablets
10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

FDA-APPROVED INDICATIONS
1
• Management of moderate to severe pain when a continuous, around-the-clock opioid
analgesic is needed for an extended period of time

COVERAGE AUTHORIZATION CRITERIA
Quantity Limit:

A quantity limit of 2 tablets per day for the 10mg, 15mg, 20mg, 30mg, 40mg, or
60mg strengths. A quantity limit of 4 tablets per day for the 80 mg strength.
Quantity Limit exception criteria:
Quantities of OxyContin that are above the program set limit will be approved when the
following criteria below are met:
A. The patient has chronic pain due to cancer, or the member is enrolled in a hospice
program or meets hospice criteria for life expectancy of six months or less; OR
B. The total daily dose cannot be achieved using a lesser quantity of a higher strength
tablet; AND
1. The patient is undergoing treatment of chronic non-cancer pain and ALL of
the following are met:
i. The prescribing physician provides documentation of a formal,
consultative evaluation including:

Diagnosis; AND
Documentation of previous pharmacological and nonpharmacological therapy; AND
 Documentation to support the use of a higher dose (quantity) for
the diagnosis given.