SEGLENTIS (celecoxib/tramadol)

SEGLENTIS (celecoxib/tramadol)

Self-Administration – oral

Diagnosis considered for coverage:

Indicated for the management of acute pain in adults that is severe enough to require an opioid analgesic and for which alternative treatments are inadequate

Coverage Criteria:

For diagnosis of acute pain:

• Dose does not exceed 2 tablets every 12 hours (224 mg/day of celecoxib and 176 mg/day of tramadol); AND
• Patient is 18 years of age or older; AND
• Chart notes document a medical reason why the patient cannot take generic tramadol and generic celecoxib as individual agents; AND
• Patient has tried and failed or has contraindications or intolerance to generic celecoxib and one other prescription strength non-steroidal anti-inflammatory drug; AND
• Patient has tried and failed generic tramadol immediate-release

Reauthorization Criteria:

For diagnosis of acute pain:

• Dose does not exceed 2 tablets every 12 hours (224 mg/day of celecoxib and 176 mg/day of tramadol); AND
• Documentation of a positive clinical response to therapy

Coverage Duration: 

• Initial: 1 year
• Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 

• Recommended dose: two 56 mg/44 mg tablets every 12 hours as needed for pain
• Contraindicated in: 
  • All patients younger than 12 years of age
  • Post-operative management in children younger than 18 years of age following tonsillectomy and/or adenoidectomy

Policy Updates:

• 8/16/2022 – New policy approved by P&T.

References:

• Seglentis Prescribing Information. Kowa Pharmaceuticals America, Inc. Montgomery, Alabama. October 2021.