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Prior Authorization Approval Criteria Ultracet (tramadol/acetaminophen) tramadol with acetaminophen Medication Class: opioid with pain reliever FDA Approved Uses: tramadol & acetaminophen: short term management of acute ultracet pain 1-2 tablets q 4-6 hrs (Maximum dose 8 tabs per day) Duration of Therapy: Criteria for use: (bullet points below are all inclusive unless otherwise noted) • Clinically documented acute pain • Failed/intolerant to preferred alternatives such as generic NSAIDs • Failed tramadol Not approved if: • Past history of substance abuse • Past history of alcohol abuse • Patient has had a history of seizures P&T Approval: ___________________________________________ Date: ______________________ Revised 12/16/12 .
Prior Authorization Approval Criteria Ultracet (tramadol/acetaminophen) tramadol with acetaminophen Medication Class: opioid with pain reliever FDA Approved Uses: tramadol & acetaminophen: ultracet 75 mg ultracet jual ultracet ultracet before or after meal altriset termite ultracet ya and short term management of acute pain 1-2 tablets q 4-6 hrs (Maximum dose 8 tabs per day) Duration of Therapy: Criteria for use: (bullet points below are all inclusive unless otherwise noted) • Clinically documented acute pain • Failed/intolerant to preferred alternatives such as generic NSAIDs • Failed tramadol Not approved if: • Past history of substance abuse • Past history of alcohol abuse • Patient has had a history of seizures P&T Approval: ___________________________________________ Date: ______________________ Revised 12/16/12 .

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