Tramadol hcl er — Blue Cross Blue Shield of New Mexico

Initial criteria

• 1. Requested agent is eligible for continuation of therapy AND prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed;
• OR 2. Patient has a diagnosis of chronic cancer pain due to an active malignancy;
• OR 3. Patient is enrolled in a hospice program or meets hospice criteria for life expectancy ≤ 6 months;
• OR 4. Prescriber is requesting palliative care or compassionate use (e.g., benefits of pain relief and patient comfort outweigh overdose/death risk) with the requested agent;
• OR 5. Patient has a diagnosis of sickle cell anemia;
• OR 6. Patient is undergoing treatment of chronic non-cancer pain AND ALL of the following:
•  A. ONE of the following subconditions:
•   1. BOTH of the following:
•    A. ONE of the following:
•     1. Prescriber has stated patient has been diagnosed with stage 4 advanced, metastatic cancer and requested agent is being used to treat the cancer, OR
•     2. Prescriber has submitted documentation that patient has been diagnosed with stage 4 advanced, metastatic cancer and requested agent is being used...