Qdolo (tramadol hydrochloride) — CareFirst (Caremark)
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate
Initial criteria
- Reserve the requested opioid for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or opioid combination products) have not been tolerated or are not expected to be tolerated AND have not provided adequate analgesia or are not expected to provide adequate analgesia.
- The product 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.
- Patient must not be receiving treatment for cancer, sickle cell disease, or palliative/hospice care as identified by prescription claim history, ICD-10 diagnosis code, or hospice residence code. Exceptions apply for those indications.
- For patients without history of cancer, sickle cell disease, palliative, or hospice care: patient is limited to a maximum of a 7-day supply per fill up to 7 days of therapy in a 90-day period. When the patient exceeds 7 days of opioid therapy for the first time in a 90-day period, prior authorization is required.
- Initial quantity limit applies providing coverage corresponding to 90 morphine milligram equivalents (MME) or less per day. Prior authorization is required for quantities exceeding the initial MME limit.
Reauthorization criteria
- Reauthorization may be considered if pain remains severe enough to require an opioid analgesic and alternative treatments continue to be inadequate.