Download MHCP Enrolled Providers – Pharmacies Fee-for

MHCP Enrolled Providers – Pharmacies
Fee-for-Service PA Criteria Sheet – Butrans
(March 2011)
Drug
Strengths
Butrans (buprenorphine) transdermal patches [Purdue]
5 mcg/hour, 10 mcg/ hour, 20 mcg/hour
FDA approved indication
Butrans (buprenorphine) is indicated for the management of moderate to severe chronic pain in patients requiring a continuous,
around-the-clock opioid analgesic for an extended period of time.
Butrans is a transdermal system (patch) providing systemic delivery of buprenorphine continuously for 7 days.
Criteria
 Patient has chronic pain requiring opiate therapy
 The patient has been tried on sustained release morphine but experienced intolerable adverse events. Ineffectiveness of
morphine to control pain is not a criteria for approval
Quantity Limits Apply: Only 4 patches per fill and only one strength allowed per patient. The maximum dose of Butrans per label
is 20 mcg/hour per label. Butrans 15 mcg/ hour (one 5 mcg/hour [patch and one 10 mcg/hour patch) will not be approved.
Exclusion Criteria
Payment for Butrans will be denied in the following situations:
 Butrans is add-on therapy to another long acting opioid. If patient is being transitioned from one opioid to Butrans, then a
discontinuation plan of the first opiod must be provided
 Patient’s current long acting ± short acting opioid dose is >80 mg morphine equivalents per day
 Patient’s current opiate is fentanyl patch strengths ≥50 mcg/hour
Approximate opioid equivalents to oral morphine
Total mg per day
Morphine
80 mg/day
Codeine
250 mg/day
Hydrocodone
40 mg/day
Hydromorphone
10 mg/day
Meperidine
400 mg/day
Methadone
30 mg/day
Oxycodone (OxyContin)
40 mg/day
Pentazocine
240 mg/day
Tramadol
800 mg/day
MHCP Provider Call Center (651) 431-2700 or 1-800-366-5411