XTAMPZA ER (oxycodone)

SELF-ADMINISTRATION - ORAL

FDA Approved Indication(s):

  • Indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. 

Initial Prior Authorization Consideration for Chronic Pain only (must meet all): 

  • Diagnosis of chronic pain; 
  • Age ≥ 18 years; 
  • Failure of two of the following unless contraindicated or clinically significant adverse effects are experienced: controlled-release morphine sulfate (MS Contin®), morphine sulfate sustained-release beads (Kadian®), transdermal fentanyl patches, extended release oxymorphone, extended-release morphine sulfate, or Oxycontin®. 
  • Chart notes including pain management treatment plan is required.

Renewal Requests for Continuation of therapy consideration (must meet all):
•    Diagnosis of Chronic Pain; 
•    Chart notes provided including continued pain management plan and documentation of patient’s positive response to therapy.

Diagnosis/Indications for which coverage is NOT authorized: 
•    Acute or intermittent pain;
•    Immediate post-surgical pain;
•    Use in patients who require opioid analgesia for a short period of time or only as needed for pain relief;
•    Any additional Non-FDA indications

Dosing:

For opioid-naïve and opioid non-tolerant patients, initiate with 9 mg PO every 12 hours. 
•    Limit daily dose to a maximum of 288 mg per day.

Available as Extended-release capsules:  9 mg, 13.5 mg, 18 mg, 27 mg, and 36 mg.

Approval:

  • Initial: 6 months
  • Renewal: 1 year


 

Last review date: April 16, 2019

Rite Aid Pharmacy Patients: All Rite Aid pharmacies nationwide are closing! Please be on the lookout for information from Rite Aid pharmacies about their bankruptcy and store closures. Call your Rite Aid pharmacy for questions about your prescriptions and new pharmacy options. WHA is here to help as well. Contact Us via Phone