Pharmacy Prior Authorization Criteria

Extended Release Tramadol Products

For diagnosis of Pain
Indicated for the management of severe and persistent pain that requires an opioid analgesic and that cannot be adequately treated with alternative options, including immediate-release opioids. Limitations of Use: Because of the risks of addiction, abuse, misuse, overdose, and death, which can occur at any dosage or duration and persist over the course of therapy, reserve opioid analgesics, including CONZIP, for use in patients for whom alternative treatment options 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 opioid analgesic and that cannot be adequately treated with alternative options, including immediate-release opioids. Limitations of Use: Because of the risks of addiction, abuse, misuse, overdose, and death, which can occur at any dosage or duration and persist over the course of therapy, reserve opioid analgesics, including tramadol hydrochloride extended-release tablets, for use in patients for whom alternative treatment options 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 (of a minimum 30 day supply) or intolerance to an immediate release tramadol containing product (e.g., tramadol, tramadol/acetaminophen)

2026-06-03, 2025-12-18, 2025-12-18, 2025-04-23, 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. Vertical Pharmaceuticals, LLC. Alpharetta, GA. December 2025.
Tramadol Extended Release prescribing information. Sun Pharmaceutical Industries, Inc. Cranbury, NJ. December 2025.

2026-06-03: 2026 Annual Review: Updated diagnosis criteria and updated to standard trial verbiage. Removed EHB formulary. Background updates and updated references.
2025-12-18: No criteria change, bulk copy oRX-EHB
2025-12-18: no criteria changes, added IL statute operational note
2025-04-23: Annual Review. No criteria changes. Updated references.
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