Value - 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 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

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

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 10-325mg

15 tablets/30 days

9 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

fentanyl dis 100mcg/h

0 patches/month

N/A

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 ot loz 1200mcg

120 lozenges / 30 days

N/A

fentanyl ot loz 1600mcg

120 lozenges / 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

hydrocodone/apap sol 7.5-325

450 mL/30 days

270 mL/30 days

hydrocodone/apap tab 10-325mg

25 tablets/30 days

15 tablets/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 /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

hydromorphone liq 1mg/ml

60 mL/30 days

36 mL/30 days

hydromorphone tab 12mg er

30 tablets/month

N/A

hydromorphone tab 16mg er

0 tablets

N/A

hydromorphone tab 2mg

30 tablets/30 days

18 tablets/30 days

hydromorphone tab 32mg er

0 tablets

N/A

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

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

MEPERIDINE TAB 50MG

30 tablets/30 days

30 tablets/30 days

methadone sol 10mg/5ml

150 mL/30 days

N/A

methadone sol 5mg/5ml

300 mL/30 days

N/A

methadone tab 10mg

30 tablets/30 days

N/A

methadone tab 5mg

60 tablets/30 days

N/A

morphine sul sol 10/0.5ml

15 mL/30 days

15 mL/30 days

morphine sul sol 100/5ml

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 tab 100mg cr

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 15mg

15 tablets/30 days

9 tablets/30 days

morphine sul tab 15mg er

60 tablets/30 days

N/A

morphine sul tab 200mg er

0 tablets/30 days

N/A

MORPHINE SUL TAB 30MG

5 tablets/30 days

3 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/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 5-325mg

30 tablets/30 days

18 tablets/30 days

oxycodone/apap tab 7.5-325

20 tablets/30 days

12 tablets/30 days

OXYCODONEASA 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 10mg

15 tablets/30 days

9 tablets/30 days

OXYCODONE TAB 10MG ER

60 tablets/30 days

N/A

oxycodone tab 15mg

10 tablets/30 days

6 tablets/30 days

OXYCODONE TAB 15MG ER

60 tablets/30 days

N/A

oxycodone tab 20mg

5 tablets/30 days

3 tablets/30 days

OXYCODONE TAB 20MG ER

30 tablets/30 days

N/A

oxycodone tab 30mg

5 tablets/30 days

3 tablets/30 days

OXYCODONE TAB 30MG ER

30 tablets/30 days

N/A

OXYCODONE TAB 40MG ER

0 tablets/30 days

N/A

oxycodone tab 5mg

30 tablets/30 days

18 tablets/30 days

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 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 5MG ER

60 tablets/30 days

N/A

OXYMORPHONE TAB 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

tramadol hcl tab 50mg

50 tablets/30 days

30 tablets/30 days


1Specialty

2Limited Distribution

3Split Fill