Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
L&I does not routinely cover transdermal fentanyl system (Duragesic) for the treatment of chronic, non-cancer pain.
L&I will cover on an exception basis transdermal system (Duragesic) when the patient requires continuous opioid analgesia for pain that cannot be managed by lesser means AND, either
- Other long-acting opioids cannot be tolerated or,
- Medical contraindications preclude the use of oral opioids (e.g., the patient can't swallow pills, the patient has dementia and might not take the right amount of pills at the right time).
Note: This does not apply to the use of opioids in the treatment of cancer pain. See WAC 296-20-03014 (2).
Use of the transdermal fentanyl system (Duragesic) for chronic, non-cancer pain will not be routinely covered. We have reviewed the literature and safety profile of this product. While the drug is absorbed relatively slowly, it reaches peak levels equivalent to intravenous use and is metabolized and excreted slowly. Therefore, because the pharmacokinetics of transdermal fentanyl demonstrates systemic availability that is equivalent to injectable routes, this product will not be routinely covered.
In addition, the FDA-approved product labeling states, in part, that Duragesic is indicated in the management of chronic pain in patients who require continuous opioid analgesia for pain that cannot be managed by lesser means.
Medical treatment guidelines: Prescribing Opioids to Treat Pain in Injured Workers (Effective July 1, 2013).