Advantage - Opioid drug list update

Effective January 1, 2022


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

Analgesics - opioid

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

ABSTRAL SUB 400MCG

120 tabs / 30 DAYS

N/A

ABSTRAL SUB 600MCG

120 tabs / 30 days

N/A

ABSTRAL SUB 800MCG

120 tabs / 30 days

N/A

ACTIQ LOZ 200MCG

120 lonzenges / 30 days

N/A

ACTIQ LOZ 400MCG

120 lonzenges / 30 days

N/A

ACTIQ LOZ 600MCG

120 lonzenges / 30 days

N/A

ACTIQ LOZ 800MCG

120 lonzenges / 30 days

N/A

ACTIQ LOZ 1200MCG

120 lonzenges / 30 days

N/A

ACTIQ LOZ 1600MCG

120 lonzenges / 30 days

N/A

APAP/CAFFEIN TAB DIHYDROCODEINE

50 tablets/30 days

30 tablets/30 days

apap/codeine sol 120-12/5

450 mL/30 days

270 mL/30 days

apap/codeine tab 300-15mg

30 tablets/30 days

18 tablets/30 days

apap/codeine tab 300-30mg

30 tablets/30 days

18 tablets/30 days

apap/codeine tab 300-60mg

25 tablets/30 days

15 tablets/30 days

APAP-CAFFEIN CAP DIHYDROCODEINE

50 capsules/30 days

30 capsules/30 days

ARYMO ER TAB 15MG

60 tablets/month

N/A

ARYMO ER TAB 30MG

30 tablets/month

N/A

ARYMO ER TAB 60MG

0 tablets/month

N/A

BELBUCA MIS 75MCG

60 films/month

N/A

BELBUCA MIS 150MCG

60 films/month

N/A

BELBUCA MIS 300MCG

60 films/month

N/A

BELBUCA MIS 450MCG

60 films/month

N/A

BELBUCA MIS 600MCG

60 films/month

N/A

BELBUCA MIS 750MCG

60 films/month

N/A

BELBUCA MIS 900MCG

30 films/month

N/A

buprenorphine dis 5mcg/hr

4 systems/month

N/A

buprenorphine dis 7.5/hr

4 systems/month

N/A

buprenorphine dis 10mcg/hr

4 systems/month

N/A

buprenorphine dis 15mcg/hr

4 systems/month

N/A

buprenorphine dis 20mcg/hr

4 systems/month

N/A

butorphanol sol 10mg/ml

2.5 mL (1 BOTTLE)/30 days

0 mL/30 days

BUTRANS DIS 5MCG/HR

4 systems/month

N/A

BUTRANS DIS 7.5/HR

4 systems/month

N/A

BUTRANS DIS 10MCG/HR

4 systems/month

N/A

BUTRANS DIS 15MCG/HR

4 systems/month

N/A

BUTRANS DIS 20MCG/HR

4 systems/month

N/A

CODEINE SULF TAB 15MG

30 tablets/30 days

18 tablets/30 days

CODEINE SULF TAB 30MG

30 tablets/30 days

18 tablets/30 days

codeine sulf tab 30mg

30 tablets/30 days

18 tablets/30 days

CODEINE SULF TAB 60MG

25 tablets/30 days

15 tablets/30 days

codeine/apap tab 30-300mg

30 tablets/30 days

18 tablets/30 days

codeine/apap tab 60-300mg

25 tablets/30 days

15 tablets/30 days

CONZIP CAP 100MG

30 capsules/30 days

N/A

CONZIP CAP 200MG

30 capsules/30 days

N/A

CONZIP CAP 300MG

30 capsules/30 days

N/A

DILAUDID LIQ 1MG/mL

60 mL/30 days

36 mL/30 days

DILAUDID TAB 2MG

30 tablets/30 days

18 tablets/30 days

DILAUDID TAB 4MG

15 tablets/30 days

9 tablets/30 days

DILAUDID TAB 8MG

5 tablets/30 days

3 tablets/30 days

DURAGESIC DIS 12MCG/HR

10 patches/month

N/A

DURAGESIC DIS 25MCG/HR

0 patches/month

N/A

DURAGESIC DIS 50MCG/HR

0 patches/month

N/A

DURAGESIC DIS 75MCG/HR

0 patches/month

N/A

DURAGESIC DIS 100MCG/HR

0 patches/month

N/A

dvorah tab 325mg/30mg/16mg

50 tablets/30 days

30 tablets/30 days

endocet tab 2.5-325

60 tablets/30 days

36 tablets/30 days

endocet tab 5-325mg

30 tablets/30 days

18 tablets/30 days

endocet tab 7.5-325

20 tablets/30 days

12 tablets/30 days

endocet tab 10-325mg

15 tablets/30 days

9 tablets/30 days

fentanyl dis 12mcg/hr

10 patches/month

N/A

fentanyl dis 25mcg/hr

0 patches/month

N/A

fentanyl dis 37.5mcg

0 patches/month

N/A

fentanyl dis 50mcg/hr

0 patches/month

N/A

fentanyl dis 62.5mcg

0 patches/month

N/A

fentanyl dis 75mcg/hr

0 patches/month

N/A

fentanyl dis 87.5mcg

0 patches/month

N/A

fentanyl dis 100mcg/hr

0 patches/month

N/A

FENTANYL CIT TAB 100MCG

120 tabs / 30 days

N/A

FENTANYL CIT TAB 200MCG

120 tabs / 30 days

N/A

FENTANYL CIT TAB 400MCG

120 tabs / 30 days

N/A

FENTANYL CIT TAB 600MCG

120 tabs / 30 days

N/A

FENTANYL CIT TAB 800MCG

120 tabs / 30 days

N/A

fentanyl ot loz 200mcg

120 lonzenges / 30 days

N/A

fentanyl ot loz 400mcg

120 lonzenges / 30 days

N/A

fentanyl ot loz 600mcg

120 lonzenges / 30 days

N/A

fentanyl ot loz 800mcg

120 lonzenges / 30 days

N/A

fentanyl ot loz 1200mcg

120 lonzenges / 30 days

N/A

fentanyl ot loz 1600mcg

120 lonzenges / 30 days

N/A

FENTORA TAB 100MCG

120 tabs / 30 days

N/A

FENTORA TAB 200MCG

120 tabs / 30 days

N/A

FENTORA TAB 400MCG

120 tabs / 30 days

N/A

FENTORA TAB 600MCG

120 tabs / 30 days

N/A

FENTORA TAB 800MCG

120 tabs / 30 days

N/A

HYDROCODONE/ACETAMINOPHEN SOL 10-325MG

375 mL/30 days

225 mL/30 days

hydrocodone/acetaminophen sol 10-325mg

375 mL/30 days

225 mL/30 days

hydrocodone/acetaminophen sol 7.5-325

450 mL/30 days

270 mL/30 days

hydrocodone/acetaminophen tab 5-300mg

40 tablets/30 days

24 tablets/30 days

hydrocodone/acetaminophen tab 5-325mg

40 tablets/30 days

24 tablets/30 days

hydrocodone/acetaminophen tab 7.5-300

30 tablets/30 days

18 tablets/30 days

hydrocodone/acetaminophen tab 7.5-325

30 tablets/30 days

18 tablets/30 days

hydrocodone/acetaminophen tab 10-300mg

25 tablets/30 days

15 tablets/30 days

hydrocodone/acetaminophen tab 10-325mg

25 tablets/30 days

15 tablets/30 days

HYDROCODONE/IBUPROFEN TAB 5-200MG

25 tablets/30 days

15 tablets/30 days

hydrocodone /ibuprofen tab 5-200mg

25 tablets/30 days

15 tablets/30 days

hydrocodone/ibuprofen tab 7.5-200

25 tablets/30 days

15 tablets/30 days

hydrocodone /ibuprofen tab 10-200mg

25 tablets/30 days

15 tablets/30 days

HYDROCODONE CAP 10MG ER

60 capsules/30 days

N/A

HYDROCODONE CAP 15MG ER

60 capsules/30 days

N/A

HYDROCODONE CAP 20MG ER

60 capsules/30 days

N/A

HYDROCODONE CAP 30MG ER

30 capsules/30 days

N/A

HYDROCODONE CAP 40MG ER

30 capsules/30 days

N/A

HYDROCODONE CAP 50MG ER

30 capsules/30 days

N/A

hydrocodone cap 10mg er

60 capsules/30 days

N/A

hydrocodone cap 15mg er

60 capsules/30 days

N/A

hydrocodone cap 30mg er

30 capsules/30 days

N/A

hydrocodone cap 40mg er

30 capsules/30 days

N/A

hydrocodone cap 50mg er

30 capsules/30 days

N/A

hydrocodone tab 20mg er

30 tablets/30 days

N/A

hydrocodone tab 30mg er

30 tablets/30 days

N/A

hydrocodone tab 40mg er

30 tablets/30 days

N/A

hydrocodone tab 60mg er

0 tablets/30 days

N/A

hydrocodone tab 80mg er

0 tablets/30 days

N/A

hydrocodone tab 100mg er

0 tablets/30 days

N/A

hydrocodone tab 120mg er

0 tablets/30 days

N/A

hydromorphone liq 1mg/ml

60 mL/30 days

36 mL/30 days

hydromorphone tab 2mg

30 tablets/30 days

18 tablets/30 days

hydromorphone tab 4mg

15 tablets/30 days

9 tablets/30 days

hydromorphone tab 8mg

5 tablets/30 days

3 tablets/30 days

hydromorphone tab 8mg er

30 tablets/month

N/A

hydromorphone tab 12mg er

30 tablets/month

N/A

hydromorphone tab 16mg er

0 tablets

N/A

hydromorphone tab 32mg er

0 tablets

N/A

HYSINGLA ER TAB 20 MG

30 tablets/30 days

N/A

HYSINGLA ER TAB 30 MG

30 tablets/30 days

N/A

HYSINGLA ER TAB 40 MG

30 tablets/30 days

N/A

HYSINGLA ER TAB 60 MG

0 tablets/30 days

N/A

HYSINGLA ER TAB 80 MG

0 tablets/30 days

N/A

HYSINGLA ER TAB 100 MG

0 tablets/30 days

N/A

HYSINGLA ER TAB 120 MG

0 tablets/30 days

N/A

KADIAN CAP 10MG ER

30 capsules/30 days

N/A

KADIAN CAP 20MG ER

30 capsules/30 days

N/A

KADIAN CAP 30MG ER

30 capsules/30 days

N/A

KADIAN CAP 40MG ER

30 capsules/30 days

N/A

KADIAN CAP 50MG ER

30 capsules/30 days

N/A

KADIAN CAP 60MG ER

0 capsules/30 days

N/A

KADIAN CAP 80MG ER

0 capsules/30 days

N/A

KADIAN CAP 100MG ER

0 capsules/30 days

N/A

KADIAN CAP 200MG ER

0 capsules/30 days

N/A

LAZANDA SPR 100MCG

30 BOTTS / 30 days

N/A

LAZANDA SPR 300MCG

30 BOTTS / 30 days

N/A

LAZANDA SPR 400MCG

30 BOTTS / 30 days

N/A

levorphanol tab 2mg

10 tablets/30 days

6 tablets/30 days

lorcet tab 5-325mg

40 tablets/30 days

24 tablets/30 days

lorcet hd tab 10-325mg

25 tablets/30 days

15 tablets/30 days

lorcet plus tab 7.5-325

30 tablets/30 days

18 tablets/30 days

LORTAB ELX 10-300MG

338 mL/30 days

203 mL/30 days

MEPERIDINE SOL 50MG/5mL

150 mL/30 days

150 mL/30 days

MEPERIDINE TAB 50MG

30 tablets/30 days

30 tablets/30 days

METHADONE SOL 5MG/5mL

300 mL/30 days

N/A

METHADONE SOL 10MG/5mL

150 mL/30 days

N/A

methadone sol 5mg/5ml

300 mL/30 days

N/A

methadone sol 10mg/5ml

150 mL/30 days

N/A

methadone tab 5mg

60 tablets/30 days

N/A

methadone tab 10mg

30 tablets/30 days

N/A

MORPHABOND TAB 15MG ER

60 tablets/30 days

N/A

MORPHABOND TAB 30MG ER

30 tablets/30 days

N/A

MORPHABOND TAB 60MG ER

0 tablets/30 days

N/A

MORPHABOND TAB 100MG ER

0 tablets/30 days

N/A

morphine sul cap 10mg er

30 capsules/30 days

N/A

morphine sul cap 20mg er

30 capsules/30 days

N/A

morphine sul cap 30mg er

30 capsules/30 days

N/A

morphine sul cap 50mg er

30 capsules/30 days

N/A

morphine sul cap 60mg er

0 capsules/30 days

N/A

morphine sul cap 80mg er

0 capsules/30 days

N/A

morphine sul cap 100mg er

0 capsules/30 days

N/A

MORPHINE SUL CAP 30MG ER

30 capsules/30 days

N/A

MORPHINE SUL CAP 40MG ER

30 capsules/30 days

N/A

MORPHINE SUL CAP 45MG ER

30 capsules/30 days

N/A

MORPHINE SUL CAP 60MG ER

0 capsules/30 days

N/A

MORPHINE SUL CAP 75MG ER

0 capsules/30 days

N/A

MORPHINE SUL CAP 90MG ER

0 capsules/30 days

N/A

MORPHINE SUL CAP 120MG ER

0 capsules/30 days

N/A

morphine sul sol 10/0.5ml

15 mL/30 days

15 mL/30 days

morphine sul sol 10mg/5ml

125 mL/30 days

75 mL/30 days

morphine sul sol 20mg/5ml

60 mL/30 days

36 mL/30 days

morphine sul sol 20mg/ml

15 mL/30 days

15 mL/30 days

morphine sul sol 100/5ml

15 mL/30 days

15 mL/30 days

morphine sul tab 15mg

15 tablets/30 days

9 tablets/30 days

morphine sul tab 30mg

5 tablets/30 days

3 tablets/30 days

MORPHINE SUL TAB 15MG

15 tablets/30 days

9 tablets/30 days

MORPHINE SUL TAB 30MG

5 tablets/30 days

3 tablets/30 days

morphine sul tab 100mg cr

0 tablets/30 days

N/A

morphine sul tab 15mg er

60 tablets/30 days

N/A

morphine sul tab 30mg er

30 tablets/30 days

N/A

morphine sul tab 60mg er

0 tablets/30 days

N/A

morphine sul tab 100mg er

0 tablets/30 days

N/A

morphine sul tab 200mg er

0 tablets/30 days

N/A

MS CONTIN TAB 15MG ER

60 tablets/30 days

N/A

MS CONTIN TAB 30MG ER

30 tablets/30 days

N/A

MS CONTIN TAB 60MG ER

0 tablets/30 days

N/A

MS CONTIN TAB 100MG ER

0 tablets/30 days

N/A

MS CONTIN TAB 200MG ER

0 tablets/30 days

N/A

NORCO TAB 5-325MG

40 tablets/30 days

24 tablets/30 days

NORCO TAB 7.5-325

30 tablets/30 days

18 tablets/30 days

NORCO TAB 10-325MG

25 tablets/30 days

15 tablets/30 days

NUCYNTA TAB 50MG

10 tablets/30 days

6 tablets/30 days

NUCYNTA TAB 75MG

5 tablets/30 days

3 tablets/30 days

NUCYNTA TAB 100MG

5 tablets/30 days

3 tablets/30 days

NUCYNTA ER TAB 50MG

60 tablets/30 days

N/A

NUCYNTA ER TAB 100MG

30 tablets/30 days

N/A

NUCYNTA ER TAB 150MG

0 tablets/30 days

N/A

NUCYNTA ER TAB 200MG

0 tablets/30 days

N/A

NUCYNTA ER TAB 250MG

0 tablets/30 days

N/A

OPANA TAB 5MG

15 tablets/30 days

9 tablets/30 days

OPANA TAB 10MG

5 tablets/30 days

3 tablets/30 days

OXAYDO TAB 5MG

30 tablets/30 days

18 tablets/30 days

OXAYDO TAB 7.5MG

20 tablets/30 days

12 tablets/30 days

OXYCODONE/ACETAMINOPHEN SOL 10/300MG

75 mL/30 days

45 mL/30 days

OXYCODONE/ASPIRIN TAB

30 tablets/30 days

18 tablets/30 days

oxycodone cap 5mg

30 capsules/30 days

18 capsules/30 days

oxycodone cap hcl 5mg

30 capsules/30 days

18 capsules/30 days

oxycodone con 10/0.5ml

5 mL/30 days

3 mL/30 days

oxycodone con 100/5ml

5 mL/30 days

3 mL/30 days

oxycodone sol 5mg/5ml

165 mL/30 days

99 mL/30 days

oxycodone tab 5mg

30 tablets/30 days

18 tablets/30 days

oxycodone tab 10mg

15 tablets/30 days

9 tablets/30 days

oxycodone tab 15mg

10 tablets/30 days

6 tablets/30 days

oxycodone tab 20mg

5 tablets/30 days

3 tablets/30 days

oxycodone tab 30mg

5 tablets/30 days

3 tablets/30 days

OXYCODONE TAB 10MG ER

60 tablets/30 days

N/A

OXYCODONE TAB 15MG ER

60 tablets/30 days

N/A

OXYCODONE TAB 20MG ER

30 tablets/30 days

N/A

OXYCODONE TAB 40MG ER

0 tablets/30 days

N/A

OXYCODONE TAB 60MG ER

0 tablets/30 days

N/A

OXYCODONE TAB 80MG ER

0 tablets/30 days

N/A

oxycodone/ acetaminophen tab 2.5-325

60 tablets/30 days

36 tablets/30 days

oxycodone/ acetaminophen tab 5-325mg

30 tablets/30 days

18 tablets/30 days

oxycodone/ acetaminophen tab 7.5-325

20 tablets/30 days

12 tablets/30 days

oxycodone/ acetaminophen tab 10-325mg

15 tablets/30 days

9 tablets/30 days

OXYCODONE/ ACETAMINOPHEN TAB 5-300MG

30 tablets/30 days

18 tablets/30 days

OXYCODONE/ ACETAMINOPHEN TAB 10-300MG

15 tablets/30 days

9 tablets/30 days

OXYCODONE/IBUPROFEN TAB 5-400MG

20 tablets/30 days

12 tablets/30 days

OXYCODONE TAB 30MG ER

30 tablets/30 days

N/A

OXYCONTIN TAB 10MG CR

60 tablets/30 days

N/A

OXYCONTIN TAB 15MG CR

60 tablets/30 days

N/A

OXYCONTIN TAB 20MG CR

30 tablets/30 days

N/A

OXYCONTIN TAB 30MG CR

30 tablets/30 days

N/A

OXYCONTIN TAB 40MG CR

0 tablets/30 days

N/A

OXYCONTIN TAB 60MG CR

0 tablets/30 days

N/A

OXYCONTIN TAB 80MG CR

0 tablets/30 days

N/A

OXYMORPHONE TAB 5MG ER

60 tablets/30 days

N/A

OXYMORPHONE TAB 7.5MG ER

60 tablets/30 days

N/A

OXYMORPHONE TAB 10MG ER

30 tablets/30 days

N/A

OXYMORPHONE TAB 15MG ER

30 tablets/30 days

N/A

OXYMORPHONE TAB 20MG ER

0 tablets/30 days

N/A

OXYMORPHONE TAB 30MG ER

0 tablets/30 days

N/A

OXYMORPHONE TAB 40MG ER

0 tablets/30 days

N/A

oxymorphone tab hcl 5mg

15 tablets/30 days

9 tablets/30 days

oxymorphone tab hcl 10mg

5 tablets/30 days

3 tablets/30 days

pentazocine/naloxone tab 50-0.5mg

10 tablets/30 days

6 tablets/30 days

PERCOCET TAB 2.5-325

60 tablets/30 days

36 tablets/30 days

PERCOCET TAB 5-325MG

30 tablets/30 days

18 tablets/30 days

PERCOCET TAB 7.5-325

20 tablets/30 days

12 tablets/30 days

PERCOCET TAB 10-325MG

15 tablets/30 days

9 tablets/30 days

PRImLEV TAB 5-300MG

30 tablets/30 days

18 tablets/30 days

PRImLEV TAB 7.5-300

20 tablets/30 days

12 tablets/30 days

PRImLEV TAB 10-300MG

15 tablets/30 days

9 tablets/30 days

PROLATE SOL 10/300MG

75 mL/30 days

45 mL/30 days

QDOLO SOL 5MG/mL

400 mL/30 days

240 mL/30 days

ROXICODONE TAB 5MG

30 tablets/30 days

18 tablets/30 days

ROXICODONE TAB 15MG

10 tablets/30 days

6 tablets/30 days

ROXICODONE TAB 30MG

5 tablets/30 days

3 tablets/30 days

SUBSYS SPR 100MCG

120 sprays / 30 days

N/A

SUBSYS SPR 200MCG

120 sprays / 30 days

N/A

SUBSYS SPR 400MCG

120 sprays / 30 days

N/A

SUBSYS SPR 600MCG

120 sprays / 30 days

N/A

SUBSYS SPR 800MCG

120 sprays / 30 days

N/A

SUBSYS SPR 1200MCG

240 sprays / 30 days

N/A

SUBSYS SPR 1600MCG

240 sprays / 30 days

N/A

tramadol/apap tab 37.5-325

40 tablets/30 days

24 tablets/30 days

TRAMADOL HCL CAP ER 100MG

30 capsules/30 days

N/A

TRAMADOL HCL CAP 150MG ER

30 capsules/30 days

N/A

TRAMADOL HCL CAP ER 200MG

30 capsules/30 days

N/A

TRAMADOL HCL CAP ER 300MG

30 capsules/30 days

N/A

tramadol hcl tab 100mg er

30 tablets/30 days

N/A

tramadol hcl tab 200mg er

30 tablets/30 days

N/A

tramadol hcl tab 300mg er

30 tablets/30 days

N/A

tramadol hcl tab 50mg

50 tablets/30 days

30 tablets/30 days

TREZIX CAP 320.5-30-16mg

50 capsules/30 days

30 capsules/30 days

TYLENOL/COD TAB #3

30 tablets/30 days

18 tablets/30 days

TYLENOL/COD TAB #4

25 tablets/30 days

15 tablets/30 days

ULTRACET TAB 37.5-325

40 tablets/30 days

24 tablets/30 days

ULTRAM TAB 50MG

50 tablets/30 days

30 tablets/30 days

XTAMPZA ER CAP 9MG

60 capsules/30 days

N/A

XTAMPZA ER CAP 13.5MG

60 capsules/30 days

N/A

XTAMPZA ER CAP 18MG

30 capsules/30 days

N/A

XTAMPZA ER CAP 27MG

30 capsules/30 days

N/A

XTAMPZA ER CAP 36MG

0 capsules/30 days

N/A

ZOHYDRO ER CAP 10MG

60 capsules/30 days

N/A

ZOHYDRO ER CAP 15MG

60 capsules/30 days

N/A

ZOHYDRO ER CAP 20MG

60 capsules/30 days

N/A

ZOHYDRO ER CAP 30MG

30 capsules/30 days

N/A

ZOHYDRO ER CAP 40MG

30 capsules/30 days

N/A

ZOHYDRO ER CAP 50MG

30 capsules/30 days

N/A


1Specialty

2Limited Distribution

3Split Fill

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