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Hydrocodone/Ibuprofen Tablets — CareFirst (Caremark)

Pain being managed through hospice or palliative care

Initial criteria

  • Authorization may be granted for Hydrocodone/Ibuprofen tablets or Tramadol/Acetaminophen tablets when the patient will NOT require use of MORE than the plan allowance of any of the following: 5 tablets per day OR 50 tablets per month of hydrocodone/ibuprofen tablets, 8 tablets per day OR 40 tablets per month of tramadol/acetaminophen tablets.
  • Quantity limits may apply: Hydrocodone/Ibuprofen – 5 tablets per day and 50 tablets per month; Tramadol/Acetaminophen – 8 tablets per day and 40 tablets per month.

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 tablets and Tramadol/Acetaminophen tablets: 1 month