Value formulary

2020 Opioids Quantity Limit ER and IR


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

Quantity Level Limits

fentanyl lozenge1

Brand (generic)

Quantity Limit

200 mcg lozenge 120 tablets/30 days
400 mcg lozenge 120 tablets/30 days
600 mcg lozenge 120 tablets/30 days
800 mcg lozenge 120 tablets/30 days
1200 mcg lozenge 120 tablets/30 days
1600 mcg lozenge 120 tablets/30 days

Quantity Limit Recommended Limits

Narcotic Analgesics

morphine sulfate ER

Brand (generic)

Quantity Limit Per 30 Days

15 mg extended-release tablet 60 tablets/month
30 mg extended-release tablet 30 tablets/month
60 mg extended-release tablet 0 tablets/month

fentanyl transdermal patch2

Brand (generic)

Quantity Limit Per 30 Days

12 mcg/hr transdermal patch 10 patches/month
25 mcg/hr transdermal patch 0 patches/month
50 mcg/hr transdermal patch 0 patches/month
75 mcg/hr transdermal patch 0 patches/month
100 mcg/hr transdermal patch 0 patches/month

hydromorphone ER2

Brand (generic)

Quantity Limit Per 30 Days

8 mg extended-release tablet 30 tablets/month
12 mg extended-release tablet 30 tablets/month
16 mg extended-release tablet 0 tablets
32 mg extended-release tablet 0 tablets

fentanyl transdermal patch2

Brand (generic)

Quantity Limit Per 30 Days

37.5 mcg/hr transdermal patch 0 patches/month
62.5 mcg/hr transdermal patch 0 patches/month
87.5 mcg/hr transdermal patch 0 patches/month

morphine sulfate ER2

Brand (generic)

Quantity Limit Per 30 Days

15 mg sustained-release tablet 60 tablets/30 days
30 mg sustained-release tablet 30 tablets/30 days
60 mg sustained-release tablet 0 tablets/30 days
100 mg sustained-release tablet 0 tablets/30 days
200 mg sustained-release tablet 0 tablets/30 days

oxymorphone SR, crush resistant ER

Brand (generic)

Quantity Limit Per 30 Days

5 mg sustained-release tablet 60 tablets/30 days
7.5 mg sustained-release tablet 60 tablets/30 days
10 mg sustained-release tablet 30 tablets/30 days
15 mg sustained-release tablet 30 tablets/30 days
20 mg sustained-release tablet 0 tablets/30 days
30 mg sustained-release tablet 0 tablets/30 days
40 mg sustained-release tablet 0 tablets/30 days

OXYCONTIN (oxycodone er)2

Brand (generic)

Quantity Limit Per 30 Days

10 mg extended-release tablet 60 tablets/30 days
15 mg extended-release tablet 60 tablets/30 days
20 mg extended-release tablet 30 tablets/30 days
30 mg extended-release tablet 30 tablets/30 days
40 mg extended-release tablet 0 tablets/30 days
60 mg extended-release tablet 0 tablets/30 days
80 mg extended-release tablet 0 tablets/30 days

NUCYNTA ER (tapentadol ER)

Brand (generic)

Quantity Limit Per 30 Days

50 mg extended-release tablet 60 tablets/30 days
100 mg extended-release tablet 30 tablets/30 days
150 mg extended-release tablet 0 tablets/30 days
200 mg extended-release tablet 0 tablets/30 days
250 mg extended-release tablet 0 tablets/30 days

tramadol er2

Brand (generic)

Quantity Limit Per 30 Days

100 mg sustained-release tablet 30 tablets/30 days
200 mg sustained-release tablet 30 tablets/30 days
300 mg sustained-release tablet 30 tablets/30 days

methadone2

Agent

Quantity Limit

5 mg tablet 60 tablets/30 days
10 mg tablet 30 tablets/30 days

methadone2

Agent

Quantity Limit

5 mg/5mL solution 300 mL/30 days
10 mg/5 mL solution 150 mL/30 days

Quantity Limit Recommended Limits

Single Ingredient Agents

Strength

Quantity Limit - Child 3 Days

Quantity Limit - Adult 5 Days

butorphanol2

10 mg/mL nasal spray

0 mL/30 days

2.5 mL (1 bottle)/30 days

CODEINE

15 mg tablet

18 tablets/30 days

30 tablets/30 days

CODEINE2

30 mg tablet

18 tablets/30 days

30 tablets/30 days

CODEINE

60 mg tablet

15 tablets/30 days

25 tablets/30 days

hydromorphone2

2 mg tablet

18 tablets/30 days

30 tablets/30 days

hydromorphone2

4 mg tablet

9 tablets/30 days

15 tablets/30 days

hydromorphone2

8 mg tablet

3 tablets/30 days

5 tablets/30 days

hydromorphone2

1 mg/mL liquid

36 mL/30 days

60 mL/30 days

LEVORPHANOL2

2 mg tablet

6 tablets/30 days

10 tablets/30 days

MEPERIDINE

50 mg tablet

30 tablets/30 days

30 tablets/30 days

MEPERIDINE

100 mg tablet

15 tablets/30 days

15 tablets/30 days

MEPERIDINE

50 mg/5 mL solution

150 mL/30 days

150 mL/30 days

MORPHINE2

30 mg tablet

3 tablets/30 days

5 tablets/30 days

oxycodone

5 mg tablet

18 tablets/30 days

30 tablets/30 days

oxycodone2

10 mg tablet

9 tablets/30 days

15 tablets/30 days

oxycodone2

20 mg tablet

3 tablets/30 days

5 tablets/30 days

oxycodone2

5 mg/5mL solution

99 mL/30 days

165 mL/30 days

oxycodone2

20 mg/mL concentrate

3 mL/30 days

5 mL/30 days

oxycodone2

15 mg tablet

6 tablets/30 days

10 tablets/30 days

oxycodone

30 mg tablet

3 tablets/30 days

5 tablets/30 days

NUCYNTA (tapentadol)

50 mg tablet

6 tablets/30 days

10 tablets/30 days

NUCYNTA (tapentadol)

75 mg tablet

3 tablets/30 days

5 tablets/30 days

NUCYNTA (tapentadol)

100 mg tablet

3 tablets/30 days

5 tablets/30 days

tramadol2

50 mg tablet

30 tablets/30 days

50 tablets/30 days


Combination Ingredient Agents

Strength

Quantity Limit - Child 3 Days

Quantity Limit - Adult 5 Days

oxycodone/ibuprofen

5 mg/400 mg tablet

12 tablets/30 days

20 tablets/30 days

hydrocodone/ibuprofen2

5 mg/200 mg tablet

15 tablets/30 days

25 tablets/30 days

hydrocodone/ibuprofen2

10 mg/200 mg tablet

15 tablets/30 days

25 tablets/30 days

hydrocodone/ibuprofen2

7.5 mg/200 mg tablet

15 tablets/30 days

25 tablets/30 days

oxycodone/aspirin2

4.8355 mg/325 mg tablet

18 tablets/30 days

30 tablets/30 days

PERCOCET, ENDOCET (oxycodone/acetaminophen)2

2.5 mg/325 mg tablet

36 tablets/30 days

60 tablets/30 days

PERCOCET, ENDOCET (oxycodone/acetaminophen)2

5 mg/325 mg tablet

18 tablets/30 days

30 tablets/30 days

PERCOCET, ENDOCET (oxycodone/acetaminophen)2

7.5 mg/325 mg tablet

12 tablets/30 days

20 tablets/30 days

PERCOCET, ENDOCET (oxycodone/acetaminophen)2

10 mg/325 mg tablet

9 tablets/30 days

15 tablets/30 days

oxycodone/acetaminophen

5 mg/325 mg/5 mL solution

60 mL/30 days

100 mL/30 days

acetaminophen/CODEINE2

120 mg/12 mg/5 mL solution

270 mL/30 days

450 mL/30 days

acetaminophen/codeine2

300 mg/15 mg tablet

18 tablets/30 days

30 tablets/30 days

acetaminophen/codeine2

300 mg/30 mg tablet

18 tablets/30 days

30 tablets/30 days

acetaminophen/codeine2

300 mg/60 mg tablet

15 tablets/30 days

25 tablets/30 days

hydrocodone/acetaminophen2

7.5 mg/325 mg/15 mL solution

270 mL/30 days

450 mL/30 days

hydrocodone/acetaminophen2

2.5 mg/325 mg tablet

36 tablets/30 days

60 tablets/30 days

hydrocodone/acetaminophen2

5 mg/325 mg tablet

24 tablets/30 days

40 tablets/30 days

hydrocodone/acetaminophen2

7.5 mg/325 mg tablet

18 tablets/30 days

30 tablets/30 days

hydrocodone/acetaminophen2

10 mg/325 mg tablet

15 tablets/30 days

25 tablets/30 days

Capital’s pharmacy policies are developed to assist in administering a member’s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any pharmacy policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this pharmacy policy and to member’s benefit information, the benefit information will govern. Capital BlueCross considers the information contained in this pharmacy policy to be proprietary and it may only be disseminated as permitted by law.


1 Generic fentanyl citrate lozenge included in program.

2 Generic available, included in quantity limit program.