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Tramadol tablets — CareFirst (Caremark)

Acute pain

Initial criteria

  • Subject to 7-day acute pain duration limit with morphine milligram equivalent (MME) limit
  • Initial 1 month and 3 month limits: ≤ 90 MME/day
  • Post 1 month and post 3 month limits: ≤ 200 MME/day
  • Quantity limits per month and 3-month supply apply as listed per strength and formulation

Reauthorization criteria

  • Reauthorization may be granted when ongoing need for therapy is documented for cancer pain, sickle cell disease, terminal, hospice, or palliative care conditions
  • Chronic pain may be reauthorized per defined duration limits

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