XTAMPZA ER (oxycodone)

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