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HumanaMedicare Advantage · Prior Auth · Medicare Advantage · Pain Management, Internal Medicine, Family Medicine +2 moreMedium impact

Tramadol extended-release products (New)

Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 15, 2026

Summary

Humana is implementing a new prior authorization policy for tramadol extended-release products (ConZip, tramadol ER capsule, and tramadol ER tablet) effective January 1, 2027. The policy establishes four mandatory approval criteria: persistent non-acute pain requiring around-the-clock treatment, pain severe enough to require opioid medication, failed trials of alternative treatments, and prior trial or inability to tolerate immediate-release tramadol 50mg. Billing teams must implement prior authorization requirements for all tramadol ER prescriptions under Medicare Advantage plans.

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What to do

by Jan 1, 2027 · 4 steps
01Billing team must update prior authorization workflows to require approval for all tramadol extended-release products (ConZip capsule, tramadol ER capsule 24hr, and tramadol ER tablet 24hr in all available strengths) before claims processing for Medicare Advantage members.
02Implement the four-criteria approval checklist in the authorization request process: (1) persistent non-acute pain requiring around-the-clock treatment, (2) pain severe enough to require opioid medication, (3) documented inadequate response to alternative treatments (nonopioid analgesics), and (4) documented trial of or contraindication to immediate-release tramadol 50mg tablet.
03Providers must submit prior authorization requests through www.humana.com/PAL using applicable preauthorization and notification lists for medical and procedural coding.
04Claims submitted without required prior authorization will be subject to denial; verify that provider ordering systems are updated to trigger authorization requests before dispensing.

Original notice

Tramadol extended-release products (New)
mcp.humana.com · Always check the source before changing claims.
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Humana policiesPain ManagementInternal MedicineFamily MedicineGeriatricsPalliative Care

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