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

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²Limited Distribution

³Split Fill

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Value - Opioid drug list update

Benefit determination

Analgesics - opioid

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days