acetaminophen and codeine tablets — CareFirst (Caremark)

Initial criteria

• Prior authorization applies only to patients age ≤ 19 years
• Medication is being used for short-term management of acute pain (acute pain duration limit of 3 days applies)
• Prescriber must confirm that alternative treatment options (e.g., non-opioid analgesics) have not been tolerated, or are not expected to be tolerated
• Prescriber must confirm that alternative treatment options have not provided adequate analgesia, or are not expected to provide adequate analgesia
• Medication should not be used for an extended period of time unless pain remains severe enough to require an opioid analgesic and alternative treatment options continue to be inadequate
• Prescriber should use the lowest effective dosage for the shortest duration consistent with patient treatment goals

Reauthorization criteria

• Reauthorization requires confirmation that pain remains severe enough to require an opioid analgesic and that alternative non-opioid treatment options continue to be inadequate

Approval duration

3 days (acute pain duration limit for patients ≤ 19 years of age)