Limited Use Note(s)
FENTANYL TRANSDERMAL SYSTEM
12mcg/hr Trans Patch
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Reason For Use Code
Clinical Criteria
689
For the treatment of chronic pain in patients who have been stabilized on fentanyl and require the use of fentanyl 12mcg/hr patches for dose adjustment up or down to the lowest optimal opioid dose.
LU Authorization Period: 1 year
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