Pharmacy Prior Authorization Criteria

Extended Release Tramadol Products

For diagnosis of Pain
Indicated for the management of severe and persistent pain that requires an extended treatment period with a daily opioid analgesic and for which alternative treatment options are inadequate. Limitations of Use: Because of the risks of addiction, abuse, and misuse with opioids, which can occur at any dosage or duration, and because of the greater risks of overdose and death with extended-release/long-acting opioid formulations, reserve CONZIP for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain. CONZIP is not indicated as an as-needed (prn) analgesic.

For diagnosis of Pain
Indicated for the management of severe and persistent pain that requires an extended treatment period with a daily opioid analgesic and for which alternative treatment options are inadequate. Limitations of Use: Because of the risks of addiction, abuse, and misuse with opioids, which can occur at any dosages or duration, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve tramadol hydrochloride extended-release tablets for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain. Tramadol hydrochloride extended-release tablet is not indicated as an as-needed (prn) analgesic.

Prior Authorization

Length of Approval: 12 Month(s)

AND

Trial and failure (of a minimum 30 day supply) or intolerance to an immediate release tramadol containing product (e.g., tramadol, tramadol/acetaminophen)

2024-05-01, 2023-10-19, 2022-10-19, 2021-10-26, 2021-09-28, 2021-05-20, 2021-01-04, 2020-08-31

Conzip prescribing information. Vectical Pharmaceuticals, LLC. Bridgewater, NJ. December 2023.
Tramadol Extended Release prescribing information. Lupin Pharmaceuticals, Inc. Baltimore, MD. January 2024.

2024-05-01: 2024 Annual Review. No criteria changes. Background updates.
2023-10-19: Annual review
2022-10-19: Annual review with no changes to criteria
2021-10-26: Annual review, updated background with no criteria changes.
2021-09-28: Addition of EHB formulary to guideline, no changes to criteria
2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
2021-01-04: Program Update: added generic Ultram ER products as targets of ST
2020-08-31: Annual Review: updated references