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Advantage - Opioid drug list update
Effective January 1, 2021
Benefit determination
The existence of this pharmacy policy does not mean that this service is a covered benefit under the member’s contract. Benefit determinations should be based in all cases on the applicable contract language. Pharmacy policies do not constitute a description of benefits. A member’s individual or group customer benefits govern which pharmaceuticals are covered, which are excluded, and which are subject to benefit limits and which require authorization. Members and providers should consult the member’s benefit information or contact us for benefit information.
Key:
UPPERCASE names = Brand
lowercase names = Generic
Transmucosal Immediate Release Fentanyl
Drug Name(s) |
Quantity Limits
|
ABSTRAL SUBLINGUAL 100MCG |
120 Tablets/30 Days |
ABSTRAL SUBLINGUAL 200MCG |
120 Tablets/30 Days |
ABSTRAL SUBLINGUAL 300MCG |
120 Tablets/30 Days |
ABSTRAL SUBLINGUAL 400MCG |
120 Tablets/30 Days |
ABSTRAL SUBLINGUAL 600MCG |
120 Tablets/30 Days |
ABSTRAL SUBLINGUAL 800MCG |
120 Tablets/30 Days |
ACTIQ LOZENGE 200MCG |
120 Lozenges/30 Days |
ACTIQ LOZENGE 400MCG |
120 Lozenges/30 Days |
ACTIQ LOZENGE 600MCG |
120 Lozenges/30 Days |
ACTIQ LOZENGE 800MCG |
120 Lozenges/30 Days |
ACTIQ LOZENGE 1200MCG |
120 Lozenges/30 Days |
ACTIQ LOZENGE 1600MCG |
120 Lozenges/30 Days |
FENTANYL CITRATE TABLET 100MCG |
120 Tablets/30 Days |
FENTANYL CITRATE TABLET 200MCG |
120 Tablets/30 Days |
FENTANYL CITRATE TABLET 400MCG |
120 Tablets/30 Days |
FENTANYL CITRATE TABLET 600MCG |
120 Tablets/30 Days |
FENTANYL CITRATE TABLET 800MCG |
120 Tablets/30 Days |
fentanyl ot lozenge 200mcg |
120 Lozenges/30 Days |
fentanyl ot lozenge 400mcg |
120 Lozenges/30 Days |
fentanyl ot lozenge 600mcg |
120 Lozenges/30 Days |
fentanyl ot lozenge 800mcg |
120 Lozenges/30 Days |
fentanyl ot lozenge 1200mcg |
120 Lozenges/30 Days |
fentanyl ot lozenge 1600mcg |
120 Lozenges/30 Days |
FENTORA TABLET 100MCG |
120 Tablets/30 Days |
FENTORA TABLET 200MCG |
120 Tablets/30 Days |
FENTORA TABLET 400MCG |
120 Tablets/30 Days |
FENTORA TABLET 600MCG |
120 Tablets/30 Days |
FENTORA TABLET 800MCG |
120 Tablets/30 Days |
LAZANDA SPRAY 100MCG |
30 Bottles/30 Days |
LAZANDA SPRAY 300MCG |
30 Bottles /30 Days |
LAZANDA SPRAY 400MCG |
30 Bottles/30 Days |
SUBSYS SPRAY 100MCG |
120 Sprays/30 Days |
SUBSYS SPRAY 200MCG |
120 Sprays/30 Days |
SUBSYS SPRAY 400MCG |
120 Sprays/30 Days |
SUBSYS SPRAY 600MCG |
120 Sprays/30 Days |
SUBSYS SPRAY 800MCG |
120 Sprays/30 Days |
SUBSYS SPRAY 1200MCG |
240 Sprays/30 Days |
SUBSYS SPRAY 1600MCG |
240 Sprays/30 Days |
Opioids Extended Release (ER)
Drug Name(s) |
Quantity Limits
|
ARYMO ER TABLET 15MG |
60 Tablets/30 Days |
ARYMO ER TABLET 30MG |
30 Tablets/30 Days |
ARYMO ER TABLET 60MG |
0 |
BELBUCA MIS 75MCG |
60 Films/30 Days |
BELBUCA MIS 150MCG |
60 Films/30 Days |
BELBUCA MIS 300MCG |
60 Films/30 Days |
BELBUCA MIS 450MCG |
60 Films/30 Days |
BELBUCA MIS 600MCG |
60 Films/30 Days |
BELBUCA MIS 750MCG |
60 Films/30 Days |
BELBUCA MIS 900MCG |
30 Films/30 Days |
buprenorphin dis 5mcg/hr |
4 Systems/30 Days |
buprenorphin dis 10mcg/hr |
4 Systems/30 Days |
buprenorphin dis 15mcg/hr |
4 Systems/30 Days |
buprenorphin dis 20mcg/hr |
4 Systems/30 Days |
BUPRENORPHIN DIS 7.5/HR |
4 Systems/30 Days |
BUTRANS DIS 5MCG/HR |
4 Systems/30 Days |
BUTRANS DIS 7.5/HR |
4 Systems/30 Days |
BUTRANS DIS 10MCG/HR |
4 Systems/30 Days |
BUTRANS DIS 15MCG/HR |
4 Systems/30 Days |
BUTRANS DIS 20MCG/HR |
4 Systems/30 Days |
CONZIP CAPSULE 100MG |
30 Capsules/30 Days |
CONZIP CAPSULE 200MG |
30 Capsules/30 Days |
CONZIP CAPSULE 300MG |
30 Capsules/30 Days |
DURAGESIC DIS 12MCG/HR |
10 Patches/30 Days |
DURAGESIC DIS 25MCG/HR |
0 |
DURAGESIC DIS 50MCG/HR |
0 |
DURAGESIC DIS 75MCG/HR |
0 |
DURAGESIC DIS 100MCG/HR |
0 |
EMBEDA CAPSULE 20-0.8MG |
30 Capsules/30 Days |
EMBEDA CAPSULE 30-1.2MG |
30 Capsules/30 Days |
EMBEDA CAPSULE 50-2MG |
30 Capsules/30 Days |
EMBEDA CAPSULE 60-2.4MG |
0 |
EMBEDA CAPSULE 80-3.2MG |
0 |
EMBEDA CAPSULE 100-4MG |
0 |
EXALGO TABLET 8MG |
30 Tablets/30 Days |
EXALGO TABLET 12MG |
30 Tablets/30 Days |
EXALGO TABLET 16MG |
0 |
EXALGO TABLET 32MG |
0 |
fentanyl dis 12mcg/hr |
10 Patches/30 Days |
fentanyl dis 25mcg/hr |
0 |
fentanyl dis 37.5mcg/hr |
0 |
fentanyl dis 50mcg/hr |
0 |
fentanyl dis 62.5mcg/hr |
0 |
fentanyl dis 75mcg/hr |
0 |
fentanyl dis 87.5mcg/hr |
0 |
fentanyl dis 100mcg/hr |
0 |
hydrocodone capsule 10mg er |
60 Capsules/30 Days |
hydrocodone capsule 15mg er |
60 Capsules/30 Days |
hydrocodone capsule 20mg er |
60 Capsules/30 Days |
hydrocodone capsule 30mg er |
30 Capsules/30 Days |
hydrocodone capsule 40mg er |
30 Capsules/30 Days |
hydrocodone capsule 50mg er |
30 Capsules/30 Days |
hydromorphone tablet 8mg er |
30 Tablets/30 Days |
hydromorphone tablet 12mg er |
30 Tablets/30 Days |
hydromorphone tablet 16mg er |
0 |
hydromorphone tablet 32mg er |
0 |
HYSINGLA ER TABLET 20 MG |
30 Tablets/30 Days |
HYSINGLA ER TABLET 30 MG |
30 Tablets/30 Days |
HYSINGLA ER TABLET 40 MG |
30 Tablets/30 Days |
HYSINGLA ER TABLET 60 MG |
0 |
HYSINGLA ER TABLET 80 MG |
0 |
HYSINGLA ER TABLET 100 MG |
0 |
HYSINGLA ER TABLET 120 MG |
0 |
KADIAN CAPSULE 10MG ER |
30 Capsules/30 Days |
KADIAN CAPSULE 20MG ER |
30 Capsules/30 Days |
KADIAN CAPSULE 30MG ER |
30 Capsules/30 Days |
KADIAN CAPSULE 40MG ER |
30 Capsules/30 Days |
KADIAN CAPSULE 50MG ER |
30 Capsules/30 Days |
KADIAN CAPSULE 60MG ER |
0 |
KADIAN CAPSULE 80MG ER |
0 |
KADIAN CAPSULE 100MG ER |
0 |
KADIAN CAPSULE 200MG ER |
0 |
MORPHABOND TABLET 15MG ER |
60 Tablets/30 Days |
MORPHABOND TABLET 30MG ER |
30 Tablets/30 Days |
MORPHABOND TABLET 60MG ER |
0 |
MORPHABOND TABLET 100MG ER |
0 |
morphine sulfate tablet 15mg |
15 Tablets/30 Days |
morphine sulfate tablet 30mg |
5 Tablets/30 Days |
morphine sulfate capsule 10mg er |
30 Capsules/30 Days |
morphine sulfate capsule 20mg er |
30 Capsules/30 Days |
morphine sulfate capsule 30mg er |
30 Capsules/30 Days |
morphine sulfate capsule 40mg er |
30 Capsules/30 Days |
morphine sulfate capsule 50mg er |
30 Capsules/30 Days |
morphine sulfate capsule 60mg er |
0 |
morphine sulfate capsule 80mg er |
0 |
morphine sulfate capsule 100mg er |
0 |
MORPHINE SULFATE CAPSULE 30MG ER |
30 Capsules/30 Days |
MORPHINESULFATE CAPSULE 45MG ER |
30 Capsules/30 Days |
MORPHINE SULFATE CAPSULE 60MG ER |
0 |
MORPHINE SULFATE CAPSULE 75MG ER |
0 |
MORPHINE SULFATE CAPSULE 90MG ER |
0 |
MORPHINE SULFATE CAPSULE 120MG ER |
0 |
morphine sulfate tablet 100mg cr |
0 |
morphine sulfate tablet 15mg er |
60 Tablets/30 Days |
morphine sulfate tablet 30mg er |
30 Tablets/30 Days |
morphine sulfate tablet 60mg er |
0 |
morphine sulfate tablet 100mg er |
0 |
morphine sulfate tablet 200mg er |
0 |
MS CONTIN TABLET 15MG ER |
60 Tablets/30 Days |
MS CONTIN TABLET 30MG ER |
30 Tablets/30 Days |
MS CONTIN TABLET 60MG ER |
0 |
MS CONTIN TABLET 100MG ER |
0 |
MS CONTIN TABLET 200MG ER |
0 |
NUCYNTA ER TABLET 50MG |
60 Tablets/30 Days |
NUCYNTA ER TABLET 100MG |
30 Tablets/30 Days |
NUCYNTA ER TABLET 150MG |
0 |
NUCYNTA ER TABLET 200MG |
0 |
NUCYNTA ER TABLET 250MG |
0 |
OPANA ER TABLET 5MG |
60 Tablets/30 Days |
OPANA ER TABLET 7.5MG |
60 Tablets/30 Days |
OPANA ER TABLET 10MG |
30 Tablets/30 Days |
OPANA ER TABLET 15MG |
30 Tablets/30 Days |
OPANA ER TABLET 20MG |
0 |
OPANA ER TABLET 30MG |
0 |
OPANA ER TABLET 40MG |
0 |
OXYCODONE TABLET 10MG ER |
60 Tablets/30 Days |
OXYCODONE TABLET 15MG ER |
60 Tablets/30 Days |
OXYCODONE TABLET 20MG ER |
30 Tablets/30 Days |
OXYCODONE TABLET 30MG ER |
30 Tablets/30 Days |
OXYCODONE TABLET 40MG ER |
0 |
OXYCODONE TABLET 60MG ER |
0 |
OXYCODONE TABLET 80MG ER |
0 |
OXYCONTIN TABLET 10MG CR |
60 Tablets/30 Days |
OXYCONTIN TABLET 15MG CR |
60 Tablets/30 Days |
OXYCONTIN TABLET 20MG CR |
30 Tablets/30 Days |
OXYCONTIN TABLET 30MG CR |
30 Tablets/30 Days |
OXYCONTIN TABLET 40MG CR |
0 |
OXYCONTIN TABLET 60MG CR |
0 |
OXYCONTIN TABLET 80MG CR |
0 |
OXYMORPHONE TABLET 5MG ER |
60 Tablets/30 Days |
OXYMORPHONE TABLET 7.5MG ER |
60 Tablets/30 Days |
OXYMORPHONE TABLET 10MG ER |
30 Tablets/30 Days |
OXYMORPHONE TABLET 15MG ER |
30 Tablets/30 Days |
OXYMORPHONE TABLET 20MG ER |
0 |
OXYMORPHONE TABLET 30MG ER |
0 |
OXYMORPHONE TABLET 40MG ER |
0 |
TRAMADOL HCL CAPSULE 150MG ER |
30 Capsules/30 Days |
TRAMADOL HCL CAPSULE ER 100MG |
30 Capsules/30 Days |
TRAMADOL HCL CAPSULE ER 200MG |
30 Capsules/30 Days |
TRAMADOL HCL CAPSULE ER 300MG |
30 Capsules/30 Days |
tramadol hcl tablet 100mg er |
30 Tablets/30 Days |
tramadol hcl tablet 200mg er |
30 Tablets/30 Days |
tramadol hcl tablet 300mg er |
30 Tablets/30 Days |
XTAMPZA ER CAPSULE 9MG |
60 Capsules/30 Days |
XTAMPZA ER CAPSULE 13.5MG |
60 Capsules/30 Days |
XTAMPZA ER CAPSULE 18MG |
30 Capsules/30 Days |
XTAMPZA ER CAPSULE 27MG |
30 Capsules/30 Days |
XTAMPZA ER CAPSULE 36MG |
0 |
ZOHYDRO ER CAPSULE 10MG |
60 Capsules/30 Days |
ZOHYDRO ER CAPSULE 15MG |
60 Capsules/30 Days |
ZOHYDRO ER CAPSULE 20MG |
60 Capsules/30 Days |
ZOHYDRO ER CAPSULE 30MG |
30 Capsules/30 Days |
ZOHYDRO ER CAPSULE 40MG |
30 Capsules/30 Days |
ZOHYDRO ER CAPSULE 50MG |
30 Capsules/30 Days |
Opioids Immediate Release (IR)
Drug Name(s) |
Adult Quantity Limit – 5 Days |
Child Quantity Limit – 3 Days |
ACETAMINOPHEN-CAFFEINE DIHYDROCODEINE CAPSULE |
50 Capsules/30 Days |
30 capsules/30 days |
ACETAMINOPHEN/CAFFEINE DIHYDROCODEINE TABLET |
50 Tablets/30 Days |
30 capsules/30 days |
acetaminophen/caffeine dihydrocodeine tablet |
50 Capsules/30 Days |
N/A |
acetaminophen/codeine solution 120-12/5 |
450 mLs/30 Days |
270 mL/30 days |
acetaminophen/codeine tablet 300-15mg |
30 Tablets/30 Days |
N/A |
acetaminophen/codeine tablet 300-30mg |
30 Tablets/30 Days |
N/A |
acetaminophen/codeine tablet 300-60mg |
25 Tablets/30 Days |
N/A |
butorphanol solution 10mg/ml |
1 Bottle/30 Days |
0 mL/30 days |
CODEINE SULFATE TABLET 15MG |
30 Tablets/30 Days |
18 tablets/30 days |
CODEINE SULFATE TABLET 30MG |
30 Tablets/30 Days |
18 tablets/30 days |
CODEINE SULFATE TABLET 60MG |
25 Tablets/30 Days |
15 tablets/30 days |
DEMEROL TABLET 100MG |
15 Tablets/30 Days |
N/A |
DILAUDID LIQUID 1MG/ML |
60 mLs/30 Days |
36 mL/30 days |
DILAUDID TABLET 2MG |
30 Tablets/30 Days |
18 tablets/30 days |
DILAUDID TABLET 4MG |
15 Tablets/30 Days |
9 tablets/30 days |
DILAUDID TABLET 8MG |
5 Tablets/30 Days |
3 tablets/30 days |
DOLOPHINE TABLET 5MG |
60 Tablets/30 Days |
N/A |
DOLOPHINE TABLET 10MG |
30 Tablets/30 Days |
N/A |
dvorah tablet |
50 Tablets/30 Days |
N/A |
endocet tablet 2.5-325 |
60 Tablets/30 Days |
36 tablets/30 days |
endocet tablet 5-325mg |
30 Tablets/30 Days |
18 tablets/30 days |
endocet tablet 7.5-325 |
20 Tablets/30 Days |
12 tablets/30 days |
endocet tablet 10-325mg |
15 Tablets/30 Days |
9 tablets/30 days |
hydrocodone/acetaminophen tablet 2.5-325mg |
60 Tablets/30 Days |
36 tablets/30 days |
hydrocodone/acetaminophen tablet 5-325mg |
40 Tablets/30 Days |
24 tablets/30 days |
hydrocodone/acetaminophen tablet 7.5-325mg |
30 Tablets/30 Days |
18 tablets/30 days |
hydrocodone/acetaminophen tablet 10-325mg |
25 Tablets/30 Days |
15 tablets/30 days |
hydrocodone/acetaminophen solution 7.5-325mg |
450 mLs/30 Days |
270 mL/30 days |
HYDROCODONE/ACETAMINOPHEN SOLUTION 10-325MG |
375 mLs/30 Days |
225 mL/30 days |
hydrocodone/acetaminophen tablet 5-300mg |
40 Tablets/30 Days |
24 tablets/30 days |
hydrocodone/acetaminophen tablet 7.5-300 mg |
30 Tablets/30 Days |
18 tablets/30 days |
hydrocodone/acetaminophen tablet 10-300mg |
25 Tablets/30 Days |
15 tablets/30 days |
hydrocodone/ibuprofen tablet 5-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
hydrocodone/ibuprofen tablet 7.5-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
hydrocodone/ibuprofen tablet 10-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
hydromorphone liquid 1mg/ml |
60 mLs/30 Days |
36 mL/30 days |
HYDROMORPHONE SUPPOSITORY 3MG |
20 Suppositories/30 Days |
N/A |
hydromorphone tablet 2mg |
30 Tablets/30 Days |
18 tablets/30 days |
hydromorphone tablet 4mg |
15 Tablets/30 Days |
9 tablets/30 days |
hydromorphone tablet 8mg |
5 Tablets/30 Days |
3 tablets/30 days |
ibudone tablet 5-200mg |
25 Tablets/30 Days |
15 tablets/30 days |
IBUDONE TABLET 10-200MG |
25 Tablets/30 Days |
15 tablets/30 days |
levorphanol tablet 2mg |
10 Tablets/30 Days |
6 tablets/30 days |
levorphanol tablet 3mg |
10 Tablets/30 Days |
6 tablets/30 days |
lorcet hd tablet 10-325mg |
25 Tablets/30 Days |
N/A |
lorcet plus tablet 7.5-325 |
30 Tablets/30 Days |
N/A |
lorcet tablet 5-325mg |
40 Tablets/30 Days |
N/A |
LORTAB ELIXER 10-300MG |
338 mLs/30 Days |
N/A |
MEPERIDINE SOLUTION 50MG/5ML |
150 mLs/30 Days |
150 mL/30 days |
meperidine tablet 50mg |
30 Tablets/30 Days |
30 tablets/30 days |
meperidine tablet 100mg |
15 Tablets/30 Days |
15 tablets/30 days |
METHADONE SOLUTION 5MG/5ML |
300 mLs/30 Days |
N/A |
METHADONE SOLUTION 10MG/5ML |
150 mLs/30 Days |
N/A |
methadone tablet 5mg |
60 Tablets/30 Days |
N/A |
methadone tablet 10mg |
30 Tablets/30 Days |
N/A |
morphine sulfate solution 10mg/5ml |
125 mLs/30 Days |
75 mL/30 days |
morphine sulfate solution 20mg/5ml |
60 mLs/30 Days |
36 mL/30 days |
morphine sulfate solution 20mg/ml |
10 mLs/30 Days |
6 mL/30 days |
MORPHINE SULFATE SUPPOSITORY 5MG |
50 Suppositories/30 Days |
N/A |
MORPHINE SULFATE SUPPOSITORY 10MG |
25 Suppositories/30 Days |
N/A |
MORPHINE SULFATE SUPPOSITORY 20MG |
10 Suppositories/30 Days |
N/A |
MORPHINE SULFATE SUPPOSITORY 30MG |
5 Suppositories/30 Days |
N/A |
MORPHINE SULFATE TABLET 15MG |
15 Tablets/30 Days |
9 tablets/30 days |
MORPHINE SULFATE TABLET 30MG |
5 Tablets/30 Days |
3 tablets/30 days |
NORCO TABLET 5-325MG |
40 Tablets/30 Days |
24 tablets/30 days |
NORCO TABLET 7.5-325 |
30 Tablets/30 Days |
18 tablets/30 days |
NORCO TABLET 10-325MG |
25 Tablets/30 Days |
15 tablets/30 days |
NUCYNTA TABLET 50MG |
10 Tablets/30 Days |
6 tablets/30 days |
NUCYNTA TABLET 75MG |
5 Tablets/30 Days |
3 tablets/30 days |
NUCYNTA TABLET 100MG |
5 Tablets/30 Days |
3 tablets/30 days |
OPANA TABLET 5MG |
15 Tablets/30 Days |
9 tablets/30 days |
OPANA TABLET 10MG |
5 Tablets/30 Days |
3 tablets/30 days |
OXAYDO TABLET 5MG |
30 Tablets/30 Days |
18 tablets/30 days |
OXAYDO TABLET 7.5MG |
20 Tablets/30 Days |
12 tablets/30 days |
oxycodone/acetaminophen tablet 2.5-325 |
60 Tablets/30 Days |
36 tablets/30 days |
oxycodone/acetaminophen tablet 5-325mg |
30 Tablets/30 Days |
18 tablets/30 days |
oxycodone/acetaminophen tablet 7.5-325 |
20 Tablets/30 Days |
12 tablets/30 days |
oxycodone/acetaminophen tablet 10-325mg |
15 Tablets/30 Days |
9 tablets/30 days |
oxycodone/aspirin tablet |
30 Tablets/30 Days |
18 tablets/30 days |
OXYCODONE/IBUPRIOFEN TABLET 5-400MG |
20 Tablets/30 Days |
12 tablets/30 days |
oxycodone capsule 5mg |
30 Capsules/30 Days |
18 capsules/30 days |
oxycodone concentrate 20/ml |
5 mLs/30 Days |
3 mL/30 days |
oxycodone solution 5mg/5ml |
165 mLs/30 Days |
99 mL/30 days |
oxycodone tablet 5mg |
30 Tablets/30 Days |
18 capsules/30 days |
oxycodone tablet 7.5mg |
20 Tablets/30 Days |
12 tablets/30 days |
oxycodone tablet 10mg |
15 Tablets/30 Days |
9 tablets/30 days |
oxycodone tablet 15mg |
10 Tablets/30 Days |
6 tablets/30 days |
oxycodone tablet 20mg |
5 Tablets/30 Days |
3 tablets/30 days |
oxycodone tablet 30mg |
5 Tablets/30 Days |
3 tablets/30 days |
OXYCODONE/ SOLUTION ACETAMINOPHEN |
100 mLs/30 Days |
60 mL/30 days |
oxymorphone tablet hcl 5mg |
15 Tablets/30 Days |
9 tablets/30 days |
oxymorphone tablet hcl 10mg |
5 Tablets/30 Days |
3 tablets/30 days |
panlor tablet 325-30 |
50 Capsules/30 Days |
N/A |
pentazocine/naloxone tablet 50-0.5mg |
10 Tablets/30 Days |
6 tablets/30 days |
PERCOCET TABLET 2.5-325 |
60 Tablets/30 Days |
36 tablets/30 days |
PERCOCET TABLET 5-325MG |
30 Tablets/30 Days |
18 tablets/30 days |
PERCOCET TABLET 7.5-325 |
20 Tablets/30 Days |
12 tablets/30 days |
PERCOCET TABLET 10-325MG |
15 Tablets/30 Days |
9 tablets/30 days |
PRIMLEV TABLET 5-300MG |
30 Tablets/30 Days |
18 tablets/30 days |
PRIMLEV TABLET 7.5-300 |
20 Tablets/30 Days |
12 tablets/30 days |
PRIMLEV TABLET 10-300MG |
15 Tablets/30 Days |
9 tablets/30 days |
ROXICODONE TABLET 5MG |
30 Tablets/30 Days |
18 tablets/30 days |
ROXICODONE TABLET 15MG |
10 Tablets/30 Days |
6 tablets/30 days |
ROXICODONE TABLET 30MG |
5 Tablets/30 Days |
3 tablets/30 days |
ROXYBOND TABLET 5MG |
30 Tablets/30 Days |
18 tablets/30 days |
tramadol hcl tablet 50mg |
50 Tablets/30 Days |
30 tablets/30 days |
tramadol/acetaminophen tablet 37.5-325 |
40 Tablets/30 Days |
24 tablets/30 days |
TREZIX CAPSULE |
50 Capsules/30 Days |
30 capsules/30 days |
TYLENOL/CODEINE TABLET #2 |
30 Tablets/30 Days |
18 tablets/30 days |
TYLENOL/CODEINE TABLET #3 |
30 Tablets/30 Days |
18 tablets/30 days |
TYLENOL/CODEINE TABLET #4 |
25 Tablets/30 Days |
15 tablets/30 days |
ULTRACET TABLET 37.5-325 |
40 Tablets/30 Days |
24 tablets/30 days |
ULTRAM TABLET 50MG |
50 Tablets/30 Days |
30 tablets/30 days |
VERDROCET TABLET 2.5-325 |
60 Tablets/30 Days |
N/A |
vicodin es tablet 7.5-300 |
30 Tablets/30 Days |
N/A |
vicodin hp tablet 10-300mg |
25 Tablets/30 Days |
N/A |
vicodin tablet 5-300mg |
40 Tablets/30 Days |
N/A |
xylon tablet 10-200mg |
25 Tablets/30 Days |
15 tablets/30 days |