Elite quarterly opioid 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

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

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/naloxone mis 12-3mg

60 films / 30 days

N/A

buprenorphine/naloxone mis 2-0.5mg

120 films / 30 days

N/A

buprenorphine/naloxone mis 4-1mg

60 tabs / 30 days

N/A

buprenorphine/naloxone mis 8-2mg

60 films / 30 days

N/A

buprenorphine/naloxone sub 2-0.5mg

120 tabs / 30 days

N/A

buprenorphine/naloxone sub 8-2mg

90 tabs / 30 days

N/A

buprenorphine sub 2mg

15 tabs / 90 days

N/A

buprenorphine sub 8mg

15 tabs / 90 days

N/A

butorphanol sol 10mg/ml

2.5 mL (1 bottle)/30 days

0 mL/30 days

codeine sulf tab 30mg

30 tablets/30 days

18 tablets/30 days

CODEINE SULF TAB 15mg

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

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/h

0 patches/month

N/A

fentanyl ot loz 200mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 400mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 600mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 800mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 1200mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 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

HYDROCOD/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 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 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

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

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

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 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 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 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 200mg er

0 tablets/30 days

N/A

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

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

oxycodone/apap tab 2.5-325

60 tablets/30 days

36 tablets/30 days

oxycodone/apap tab 5-325mg

30 tablets/30 days

18 tablets/30 days

oxycodone/apap tab 7.5-325

20 tablets/30 days

12 tablets/30 days

oxycodone/apap tab 10-325mg

15 tablets/30 days

9 tablets/30 days

OXYCOD/ASPIRIN TAB

30 tablets/30 days

18 tablets/30 days

OXYCOD/IBUPROFEN TAB 5-400mg

20 tablets/30 days

12 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

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

tramadol/apap tab 37.5-325

40 tablets/30 days

24 tablets/30 days

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

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

ZUBSOLV SUB 0.7-0.18

30 tabs / 30 days

N/A

ZUBSOLV SUB 1.4-0.36

90 tabs / 30 days

N/A

ZUBSOLV SUB 2.9-0.71

30 tabs / 30 days

N/A

ZUBSOLV SUB 5.7-1.4

30 tabs / 30 days

N/A

ZUBSOLV SUB 8.6-2.1

60 tabs / 30 days

N/A

ZUBSOLV SUB 11.4-2.9

30 tabs / 30 days

N/A