CHIP - 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
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
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
buprenorphine dis 5mcg/hr	4 systems/month	N/A
butorphanolsol 10mg/ml	2.5 mL (1 bottle)/30 days	0 mL/30 days
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 60MG	25 tablets/30 days	15 tablets/30 days
EMBEDA CAP 100-4MG	0 capsules/month	N/A
EMBEDA CAP 20-0.8MG	30 capsules/month	N/A
EMBEDA CAP 30-1.2MG	30 capsules/month	N/A
EMBEDA CAP 50-2MG	30 capsules/month	N/A
EMBEDA CAP 60-2.4MG	0 capsules/month	N/A
EMBEDA CAP 80-3.2MG	0 capsules/month	N/A
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 50mcg/hr	0 patches /month	N/A
fentanyl dis 75mcg/hr	0 patches /month	N/A
fentanyl dis 100mcg/hr	0 patches /month	N/A
fentanyl otloz 200mcg	120 lozenges/ 30 days	N/A
fentanyl otloz 400mcg	120 lozenges / 30 days	N/A
fentanyl otloz 600mcg	120 lozenges / 30 days	N/A
fentanyl otloz 800mcg	120 lozenges / 30 days	N/A
fentanyl otloz 1200mcg	120 lozenges / 30 days	N/A
fentanyl otloz 1600mcg	120 lozenges / 30 days	N/A
hydrocodone/apap sol 7.5-325	450 mL/30 days	270 mL/30 days
hydrocodone /apap tab 5-325mg	40 tablets/30 days	24 tablets/30 days
hydrocodone /apap tab 7.5-325	30 tablets/30 days	18 tablets/30 days
hydrocodone /apap 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
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
levorphanoltab 2mg	10 tablets/30 days	6 tablets/30 days
lorcet tab 5-325mg	40 tablets/30 days	24 tablets/30 days
lorcethd tab 10-325mg	25 tablets/30 days	15 tablets/30 days
lorcet plustab 7.5-325	30 tablets/30 days	18 tablets/30 days
MEPERIDINE SOL 50MG/5mL	150 mL/30 days	150 mL/30 days
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
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 100mg er	0 tablets/30 days	N/A
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 30mg er	30 tablets/30 days	N/A
morphine sul tab 60mg er	0 tablets/30 days	N/A
NUCYNTA TAB 100MG	5 tablets/30 days	3 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 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
NUCYNTA ER TAB 50MG	60 tablets/30 days	N/A
oxycodone/apaptab 2.5-325	60 tablets/30 days	36 tablets/30 days
oxycodone/apaptab 5-325mg	30 tablets/30 days	18 tablets/30 days
oxycodone/apaptab 7.5-325	20 tablets/30 days	12 tablets/30 days
oxycodone/apaptab 10-325mg	15 tablets/30 days	9 tablets/30 days
OXYCODONE/ASPARIN TAB	30 tablets/30 days	18 tablets/30 days
OXYCODONE/IBUPROFEN TAB 5-400MG	20 tablets/30 days	12 tablets/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 30MG 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
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
OXYMORPHONETAB 5MG ER	60 tablets/30 days	N/A
OXYMORPHONETAB 7.5MG ER	60 tablets/30 days	N/A
OXYMORPHONETAB 10MG ER	30 tablets/30 days	N/A
OXYMORPHONETAB 15MG ER	30 tablets/30 days	N/A
OXYMORPHONETAB 20MG ER	0 tablets/30 days	N/A
OXYMORPHONETAB 30MG ER	0 tablets/30 days	N/A
OXYMORPHONETAB 40MG ER	0 tablets/30 days	N/A
tramadol hcl tab 50mg	50 tablets/30 days	30 tablets/30 days
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
OXYMORPHONETAB 5MG ER	60 tablets/30 days	N/A
OXYMORPHONETAB 7.5MG ER	60 tablets/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

¹Specialty

²Limited Distribution

³Split Fill

Complementary Content

${loading}

Web Content Viewer - Metadata

Breadcrumb DnD

Web Content Viewer - Fixed Context

CHIP - Opioid drug list update

Benefit determination

Analgesics - opioid

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context