Administrative Policy effective January 1, 2020

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Use Management Requirement Change for OxyContin Effective June 1

We would like you to be aware of an upcoming policy update involving the opioid medication OxyContin. Starting June 1, 2019, the existing prior authorization requirements for OxyContin will be updated. In addition to the medical necessity criteria for long acting opioid therapy, OxyContin will require a trial (drug failure or serious side effects) of Oxycodone ER (authorized generic for OxyContin) OR Xtampza ER.

Oxycodone ER is the authorized generic of OxyContin and is available in the same strengths as OxyContin. Xtampza ER is a long acting Oxycodone product available in capsules that are dosed every 12 hours. Both Oxycodone ER and Xtampza ER are available in abuse deterrent formulations; Oxycodone ER is formulated with polyethylene oxide and, in the presence of water, the new formulation will form a viscous liquid which will make it more difficult to draw the medication up in a syringe. Xtampza ER contains microspheres formulated with inactive ingredients intended to make the formulation more difficult to manipulate for misuse and abuse.

Patients receiving other oral Oxycodone formulations may be converted to Xtampza ER using the same total daily dose of Oxycodone by administering one-half of the patient’s total daily oral oxycodone dose as Xtampza ER every 12 hours with food.

Equivalence table for dosage strength of Oxycodone HCL salt and Oxycodone base (Xtampza ER)1:

For example, if a patient is taking OxyContin 20mg every 12 hours, an appropriate therapeutic switch to Xtampza would be 18mg every 12 hours. Of note, the daily dose of Xtampza ER must be limited to a maximum of 288mg per day (equivalent to 320mg Oxycodone HCL per day).

This policy change was reviewed and approved by our Pharmacy & Therapeutics (P&T) Committee, which is comprised of local physicians and pharmacists who are not employed by our health plan.

For commercial, exchange, Medicaid and Child Health Plus members, starting June 1, 2019, the updated prior authorization requirements for OxyContin will apply to new users only. For your patients with a previous authorization for OxyContin, they will be evaluated based on the new criteria upon recertification. This change does not apply to Medicare members.

OxyContin alternatives chart

* Tier placement applicable for commercial and exchange members

If submitting a coverage request for OxyContin, please include the following relevant clinical information:

  • Clinical documentation of drug failure or serious side effects to Oxycodone ER or Xtampza ER

If you and your patient decide that the alternative medication is not the right choice, you can request a Step Therapy Override pursuant to Insurance Law 4903, if applicable.  Please use

our Opioid Therapy Evaluation Form available at > Authorizations > Authorization Request Forms > Drug Exception Forms > Opioid Prior Authorization Request Form for Drug and Morphine Milligram Equivalents Reviews (Opioid Therapy Evaluation).

The completed form should be faxed to our Pharmacy Unit for therapy consideration at 1-800-956-2397. You can submit a request via electronic prior authorization (ePA) by going to or through any ePA-enabled EMR software.

If you have any questions about this information, please call 1-800-920-8889 or email us at

Thank you for the quality of care and service that you provide to our members.


1 Xtampza ER (oxycodone) extended-release capsules [prescribing information]. Stoughton, MA: Collegium Pharmaceutical; April 2019.

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