90 dosage units per 90 days OR. Extended-release Formulations Ultram ER 90 dosage units per 90 days OR

Transcription

1 Pre - PA Allowance 12 years of age or older Quantity Immediate-release Formulation Ultracet 720 dosage units per 90 days OR Ultram 720 dosage units per 90 days Extended-release Formulations Ultram ER 90 dosage units per 90 days OR Conzip 90 dosage units per 90 days OR Tramadol ER 90 dosage units per 90 days Maximum daily limit of any combination: 300mg *Utilizing the highest strengths available to achieve the dosage is recommended to minimize dosing errors and improve compliance Prior-Approval Requirements Diagnosis Ultram (tramadol) 16 years of age or older Moderate to severe pain 1. NO dual therapy with other immediate release opioid analgesic(s)

2 1. Physician agrees to taper patient s dose to the maximum FDA allowable dose based on their daily dose a. Patients taking over 600mg daily will be required to taper to 600mg daily b. Patients at 600mg or less daily will be required to taper to 400mg daily Ultracet (tramadol and acetaminophen) 16 years of age or older Moderate to severe pain 1. NO dual therapy with other immediate release opioid analgesic(s) 1. Physician agrees to taper patient s dose to the maximum FDA allowable dose based on their daily dose a. Patients taking over 600mg daily will be required to taper to 500mg daily b. Patients at 600mg or less daily will be required to taper to 300mg daily

3 Ultram ER and Conzip (tramadol ER) 18 years of age or older Moderate to severe pain requiring daily, around-the-clock long term opioid treatment 1. NO dual therapy with other long acting opioid analgesic(s) 2. Alternative treatment options have been ineffective, not tolerated or inadequate for controlling the pain i. These include: non-opioid analgesics and immediate release analgesics 3. Prescriber agrees to assess the benefits of pain control (i.e. Care Plan 4. Prescriber agrees to assess patient for serotonin syndrome 5. NO dual therapy with opioid addiction treatment or methadone 6. NO dual therapy with an anti-anxiety benzodiazepine(s) 1. Physician agrees to taper patient s dose to the maximum FDA allowable dose based on their daily dose a. Patients taking over 600mg daily will be required to taper to 500mg daily b. Patients at 600mg or less daily will be required to taper to 300mg daily

4 Prior - Approval Limits Quantity Immediate-release Formulation Above 600mg daily dose Ultracet 1080 dosage units per 90 days OR Ultram 1440 dosage units per 90 days OR 600mg or less daily dose Ultracet 900 dosage units per 90 days OR Ultram 1080 dosage units per 90 days Extended-release Formulations Above 600mg daily dose Conzip / Tramadol ER / Ultram ER 100mg 540 dosage units per 90 days OR Tramadol ER 150mg 360 dosage units per 90 days OR Conzip / Tramadol ER / Ultram ER 200mg 270 dosage units per 90 days OR Conzip / Tramadol ER / Ultram ER 300mg 180 dosage units per 90 days Maximum daily limit of any combination: 600mg 600mg or less daily dose Conzip / Tramadol ER / Ultram ER 100mg 360 dosage units per 90 days OR Tramadol ER 150mg 180 dosage units per 90 days OR Conzip / Tramadol ER / Ultram ER 200mg 180 dosage units per 90 days OR Conzip / Tramadol ER / Ultram ER 300mg 135 dosage units per 90 days Maximum daily limit of any combination: 400mg Duration 6 months Prior Approval Renewal Requirements Diagnosis Ultram (tramadol) 16 years of age or older Moderate to severe pain

5 1. NO dual therapy with other immediate release opioid analgesic(s) 1. Physician agrees to taper patient s dose to the maximum FDA allowable dose of 400mg daily Ultracet (tramadol and acetaminophen) 16 years of age or older Moderate to severe pain 1. NO dual therapy with other immediate release opioid analgesic(s)

6 1. Physician agrees to taper patient s dose to the maximum FDA allowable dose of 300mg daily Ultram ER and Conzip (tramadol ER) 18 years of age or older Moderate to severe pain requiring daily, around-the-clock long term opioid treatment 1. NO dual therapy with other long acting opioid analgesic(s) 1. Physician agrees to taper patient s dose to the maximum FDA allowable dose of 300mg daily Prior - Approval Renewal Limits Quantity Immediate-release Formulation Ultracet 900 dosage units per 90 days OR Ultram 1080 dosage units per 90 days OR Extended-release Formulations Conzip / Tramadol ER / Ultram ER 100mg 360 dosage units per 90 days OR

7 Tramadol ER 150mg 180 dosage units per 90 days OR Conzip / Tramadol ER / Ultram ER 200mg 180 dosage units per 90 days OR Conzip / Tramadol ER / Ultram ER 300mg 135 dosage units per 90 days Maximum daily limit of any combination: 400mg Duration 6 months - One renewal only for patients with an initial daily dose above 600mg

8 Appendix 1 - List of Serotonergic Medications Selective Serotonin Reuptake Inhibitors (SSRIs) paroxetine Paxil, Paxil CR, Pexeva, Brisdelle fluvoxamine Luvox, Luvox CR fluoxetine Prozac, Prozac Weekly, Sarafem, Selfemra, Symbyax sertraline Zoloft citalopram Celexa escitalopram Lexapro Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) venlafaxine Effexor XR desvenlafaxine Pristiq, Khedezla duloxetine Cymbalta milnacipran Savella Tricyclic Antidepressants (TCAs) amitriptyline No brand name currently marketed desipramine Norpramin clomipramine Anafranil imipramine Tofranil, Tofranil PM nortriptyline Pamelor, Aventyl protriptyline Vivactil doxepin Zonalon, Silenor trimipramine Surmontil Monoamine Oxidase Inhibitors (MAOIs) isocarboxazid Marplan phenelzine Nardil selegiline Emsam, Eldepryl, Zelapar tranylcypromine Parnate Other Psychiatric Medicines amoxapine No brand name currently marketed maprotiline No brand name currently marketed nefazodone No brand name currently marketed trazodone Oleptro buspirone No brand name currently marketed vilazodone Viibryd mirtazapine Remeron, Remeron Soltab llthium Lithobid

9 Migraine Medicines almotriptan Axert frovatriptan Frova naratriptan Amerge rizatriptan Maxalt, Maxalt-MLT sumatriptan Imitrex, Imitrex Statdose, Alsuma, Sumavel Dosepro, Zecuity, Treximet zolmitriptan Zomig, Zomig-ZMT Antiemetics ondansetron granisetron dolasetron palonosetron Zofran, Zofran ODT, Zuplenz Kytril, Sancuso Anzemet Aloxi Other Serotonergic Medicines dextromethorphan Bromfed-DM, Delsym, Mucinex DM, Nuedexta linezolid Zyvox cyclobenzaprine Amrix methylene blue St. John s wort tryptophan