Us Family Health Plan Pharmacy Program Medical Necessity Form For Nucynta (Tapentadol)
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1
2Medical Necessity Criteria for Tapentadol (Nucynta)
Drug Class – Narcotic Analgesics
Background – After evaluating the relative clinical and cost effectiveness of medications in this class (the
narcotic analgesics), the DoD P&T Committee recommended that tapentadol (Nucynta) be designated as non-
formulary. This recommendation has been approved by the Director, TMA.
Effective Date: 14 April 2010
Patients currently using a nonformulary narcotic analgesic may wish to ask their doctor to consider a formulary
alternative
.
Special Notes:
1. Active duty cost share always $0 in all points of service for all three tiers; Active duty cost share always
$0 in all points of service for all three tiers; TRICARE does not cover non-formulary medications for
active duty service members unless they are determined to be medically necessary.
2. MTFs will be able to fill non-formulary requests for non-formulary medications only if both of the
following conditions are met: 1) a MTF provider writes the prescription, and 2) medical necessity is
established for the non-formulary medication. MTFs may (but are not required to) fill a prescription for a
non-formulary medication written by a non-MTF provider to whom the patient was referred, as long as
medical necessity has been established.
3. Use of narcotic analgesic varies widely among products. Reasonable formulary alternatives for Nucynta
within this medication class are presented in the table above.
4.
Medical Necessity Criteria for Tapentadol (Nucynta)
The non-formulary cost share for Nucynta may be reduced to the formulary cost share if the patient meets any of the
following criteria:
1.
Use of formulary narcotic analgesics is contraindicated (e.g., due to hypersensitivity to a dye or other inert
ingredient) and treatment with Nucynta is not contraindicated.
2.
The patient previously responded to Nucynta and changing to a formulary narcotic analgesic would incur
unacceptable clinical risk (e.g., loss of pain control). The patient is unable to take oral medications.
Criteria approved through the DoD P&T Committee process November, 2009
is the official Web site of the
TRICARE Management Activity,
a component of the
Military Health System
Skyline 5, Suite 810, 5111 Leesburg Pike,
Falls Church, VA 22041-3206
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