Limited coverage criteria – fentanyl (patch)

12.5 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 100 mcg patch

1. Diagnosis of cancer
   AND
   patient is unresponsive or intolerant to conventional, titrated opioids such as codeine or oxycodone and morphine or hydromorphone

OR

2. Pain management in a specified chronic pain diagnosis*
   AND
   patient is unresponsive or intolerant to conventional, titrated opioids such as codeine or oxycodone and morphine or hydromorphone

OR

3. Person uses non-prescribed opioids, is at risk of harm from the toxic street drug supply, and is not fentanyl-naive

Initial: 1 year

Renewal: 1 year