Exclusive - 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 LOZENGE 1200MCG	120 lozenges / 30 days	N/A
ACTIQ LOZENGE 1600MCG	120 lozenges / 30 days	N/A
ACTIQ LOZENGE 200MCG	120 lozenges / 30 days	N/A
ACTIQ LOZENGE 400MCG	120 lozenges / 30 days	N/A
ACTIQ LOZENGE 600MCG	120 lozenges / 30 days	N/A
ACTIQ LOZENGE 800MCG	120 lozenges / 30 days	N/A
APAP/CAFFEINE TAB DIHYDROCODONE	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-CAFFEINE CAP DIHYDROCODONE	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 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 75MCG	60 films/month	N/A
BELBUCA MIS 900MCG	30 films/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
buprenorphine dis 7.5/hr	4 systems/month	N/A
butorphanol sol 10mg/ml	2.5 mL (1 BOTTLE)/30 days	0 mL/30 days
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
BUTRANS DIS 5MCG/HR	4 systems/month	N/A
BUTRANS DIS 7.5/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 100MCG/H	0 patches/month	N/A
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
dvorah tab	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 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 dis 37.5mcg	0 patches/month	N/A
fentanyl dis 62.5mcg	0 patches/month	N/A
fentanyl dis 87.5mcg	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 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
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/apap sol 7.5-325	450 mL/30 days	270 mL/30 days
hydrocodone/apap tab 5-300mg	40 tablets/30 days	24 tablets/30 days
hydrocdone/apap tab 5-325mg	40 tablets/30 days	24 tablets/30 days
hydrocdone/apap tab 7.5-300	30 tablets/30 days	18 tablets/30 days
hydrocodone/apap tab 7.5-325	30 tablets/30 days	18 tablets/30 days
hydrocodone/apap tab 10-300mg	25 tablets/30 days	15 tablets/30 days
hydrocodone/apap tab 10-325mg	25 tablets/30 days	15 tablets/30 days
hydrocodone/ibuprofen tab 10-200mg	25 tablets/30 days	15 tablets/30 days
HYDROCODONE/IBUPROFEN TAB 5-200MG	25 tablets/30 days	15 tablets/30 days
hydrocodone/ibuprofen tab 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 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
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 100 MG	0 tablets/30 days	N/A
HYSINGLA ER TAB 120 MG	0 tablets/30 days	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
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/APAP TAB 10-300MG	15 tablets/30 days	9 tablets/30 days
oxycodone/apap tab 5-325mg	30 tablets/30 days	18 tablets/30 days
oxycodone/apap tab 10-325mg	15 tablets/30 days	9 tablets/30 days
oxycodone/apap tab 2.5-325	60 tablets/30 days	36 tablets/30 days
oxycodone/apap tab 7.5-325	20 tablets/30 days	12 tablets/30 days
OXYCODONE/APAP TAB 5-300MG	30 tablets/30 days	18 tablets/30 days
OXYCODONE/IBUPROFEN TAB 5-400MG	20 tablets/30 days	12 tablets/30 days
OXYCODONE/ASA 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 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
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 150MG ER	30 capsules/30 days	N/A
TRAMADOL HCL CAP ER 100MG	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
tramadolhcl tab 100mg er	30 tablets/30 days	N/A
tramadolhcl tab 200mg er	30 tablets/30 days	N/A
tramadolhcl tab 300mg er	30 tablets/30 days	N/A
tramadolhcl tab 50mg	50 tablets/30 days	30 tablets/30 days
TREZIX CAP	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 13.5MG	60 capsules/30 days	N/A
XTAMPZA ER CAP 9MG	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

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Exclusive - Opioid drug list update

Benefit determination

Analgesics - opioid

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days