CHIP – Opioid (QLL) 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 
(per 30 days or as specified)

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

Opioids Extended Release (ER)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

fentanyl dis 12mcg/hr

10 Patches/30 Days

fentanyl dis 25mcg/hr

0

fentanyl dis 50mcg/hr

0

fentanyl dis 75mcg/hr

0

fentanyl dis 100mcg/hr

0

hydromorphone tablet 12mg er

30 Tablets/30 Days

hydromorphone tablet 16mg er

0

hydromorphone tablet 32mg er

0

hydromorphone tablet 8mg er

30 Tablets/30 Days

morphine sulfate tablet 15mg

15 Tablets/30 Days

morphine sulfate tablet 30mg

5 Tablets/30 Days

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

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

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

30 Tablets/30 Days

OXYMORPHONE TABLET 30MG ER

0

OXYMORPHONE TABLET 40MG ER

0

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

Opioids Immediate Release (IR)

Drug Name(s)

Adult Quantity Limit – 5 Days

Child Quantity Limit – 3 Days

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

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/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 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

levorphanol tablet 2mg

10 Tablets/30 Days

6 tablets/30 days

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

10 mLs/30 Days

N/A

METHADONE SOLUTION 10MG/5ML

5 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 100/5ml

10 mLs/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 TABLET 15MG

15 Tablets/30 Days

9 tablets/30 days

MORPHINE SULFATE TABLET 30MG

5 Tablets/30 Days

3 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

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/IBUPROFEN TABLET 5-400MG

20 Tablets/30 Days

12 tablets/30 days

oxycodone concentrate 100/5ml

5 mLs/30 Days

N/A

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 10mg

15 Tablets/30 Days

9 capsules/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

tramadol hcl tablet 50mg

50 Tablets/30 Days

30 tablets/30 days

1Specialty

2Limited Distribution

3Split Fill