dihydrocodeine/caffeine/acetaminophen — CareFirst (Caremark)

Initial criteria

• The patient can safely take the requested dose based on their history of opioid use.
• The patient has been evaluated and will be monitored regularly for the development of opioid use disorder.
• The patient’s pain will be reassessed in the first month after the initial prescription or any dose increase AND every 3 months thereafter to ensure that clinically meaningful improvement in pain and function outweigh risks to patient safety.
• For hydrocodone/ibuprofen tablets: the patient will NOT require use of more than 5 tablets per day OR 50 tablets per month (quantity sufficient for a 10-day supply).
• For tramadol/acetaminophen tablets: the patient will NOT require use of more than 8 tablets per day OR 40 tablets per month (quantity sufficient for a 5-day supply).

Approval duration

Pain associated with cancer, sickle cell disease, terminal condition, or hospice/palliative care: 12 months; Chronic pain: 6 months; Acute pain: 1 month; Hydrocodone/Ibuprofen and Tramadol/Acetaminophen tablets: 1 month