Value - Opioid (QLL) drug list update

Effective January 1, 2021


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

Transmucosal Immediate Release Fentanyl

Drug name(s)

Quantity limits 
(per 30 days or as specified)

fentanyl ot lozenge 200mcg

120 lozenges/30 days

fentanyl ot lozenge 400mcg

120 lozenges/30 days

fentanyl ot lozenge 600mcg

120 lozenges/30 days

fentanyl ot lozenge 800mcg

120 lozenges/30 days

fentanyl ot lozenge 1200mcg

120 lozenges/30 days

fentanyl ot lozenge 1600mcg

120 lozenges/30 days

Opioids Extended Release (ER)

Drug Name(s)

Quantity limits 
(per 30 days or as specified)

fentanyl dis 12mcg/hr

10 patches/30 days

fentanyl dis 25mcg/hr

0

fentanyl dis 50mcg/hr

0

fentanyl dis 75mcg/hr

0

fentanyl dis 100mcg/h

0

hydromorphone name(s)t 8mg er

30 name(s)ts/30 days

hydromorphone name(s)t 12mg er

30 name(s)ts/30 days

hydromorphone name(s)t 16mg er

0

hydromorphone name(s)t 32mg er

0

morphine sulfate name(s)t 15mg er

60 name(s)ts/30 days

morphine sulfate name(s)t 30mg er

30 name(s)ts/30 days

morphine sulfate name(s)t 60mg er

0

morphine sulfate name(s)t 100mg cr

0

morphine sulfate name(s)t 100mg er

0

morphine sulfate name(s)t 200mg er

0

NUCYNTA ER name(s)T 50MG

60 name(s)ts/30 days

NUCYNTA ER name(s)T 100MG

0

NUCYNTA ER name(s)T 150MG

0

NUCYNTA ER name(s)T 200MG

0

NUCYNTA ER name(s)T 250MG

0

OXYCODONE name(s)T 10MG ER

60 name(s)ts/30 days

OXYCODONE name(s)T 15MG ER

60 name(s)ts/30 days

OXYCODONE name(s)T 20MG ER

30 name(s)ts/30 days

OXYCODONE name(s)T 30MG ER

30 name(s)ts/30 days

OXYCODONE name(s)T 40MG ER

0

OXYCODONE name(s)T 60MG ER

0

OXYCODONE name(s)T 80MG ER

0

OXYCONTIN name(s)T 10MG CR

60 name(s)ts/30 days

OXYCONTIN name(s)T 15MG CR

60 name(s)ts/30 days

OXYCONTIN name(s)T 20MG CR

30 name(s)ts/30 days

OXYCONTIN name(s)T 30MG CR

30 name(s)ts/30 days

OXYCONTIN name(s)T 40MG CR

0

OXYCONTIN name(s)T 60MG CR

0

OXYCONTIN name(s)T 80MG CR

0

OXYMORPHONE name(s)T 5MG ER

60 name(s)ts/30 days

OXYMORPHONE name(s)T 7.5MG ER

60 name(s)ts/30 days

OXYMORPHONE name(s)T 10MG ER

30 name(s)ts/30 days

OXYMORPHONE name(s)T 15MG ER

30 name(s)ts/30 days

OXYMORPHONE name(s)T 20MG ER

0 name(s)ts/30 days

OXYMORPHONE name(s)T 30MG ER

0

OXYMORPHONE name(s)T 40MG ER

0

tramadol hcl name(s)t 100mg er

30 name(s)ts/30 days

tramadol hcl name(s)t 200mg er

30 name(s)ts/30 days

tramadol hcl name(s)t 300mg er

30 name(s)ts/30 days

morphine sulfate name(s)t 15mg

15 name(s)ts/30 days

morphine sulfate name(s)t 30mg

15 name(s)ts/30 days

Opioids Immediate Release (IR)

Drug name(s)

Adult quantity limit – 5 days

Child quantity limit – 3 days

acetaminophen/codeine solution 120-12/5

450 mLs/30 days

270 mL/30 days

acetaminophen/codeine tablet 300-15mg

30 tablets/30 days

18 tablets/30 days

acetaminophen/codeine tablet 300-30mg

30 tablets/30 days

18 tablets/30 days

acetaminophen/codeine tablet 300-60mg

25 tablets/30 days

15 tablets/30 days

butorphanol solution 10mg/ml

1 bottle/30 days

N/A

CODEINE SULFATE TABLET 15MG

30 tablets/30 days

N/A

codeine sulfate tablet 30mg

30 tablets/30 days

N/A

CODEINE SULFATE TABLET 60MG

25 tablets/30 days

N/A

codeine/acetaminophen tablet 30-300mg

30 tablets/30 days

N/A

codeine/acetaminophen table 60-300mg

25 tablets/30 days

N/A

codeine/acetaminophen 120 mg/12 mg/5 mL solution

450 mLs/30 days

N/A

endocet tablet 2.5-325

60 tablets/30 days

N/A

endocet tablet 5-325mg

18 tablets/30 days

N/A

endocet tablet 7.5-325

20 tablets/30 days

N/A

endocet tablet 10-325mg

15 tablets/30 days

N/A

HYDROCODONE/ACETAMINOPHEN TABLET 2.5-325

60 tablets/30 days

36 tablets/30 days

hydrocodone/acetaminophen tablet 2.5-325

60 tablets/30 days

36 tablets/30 days

hydrocodone/acetaminophen tablet 5-325mg

40 tablets/30 days

24 tablets/30 days

hydrocodone/acetaminophen tablet 7.5-325

30 tablets/30 days

18 tablets/30 days

hydrocodone/acetaminophen tablet 10-325mg

25 tablets/30 days

15 tablets/30 days

hydrocodone/ibuprofen tablet 5-200mg

25 tablets/30 days

15 tablets/30 days

hydrocodone/ibuprofen tablet 7.5-200

25 tablets/30 days

15 tablets/30 days

hydrocodone/ibuprofen tablet 10-200mg

25 tablets/30 days

15 tablets/30 days

hydromorphone liquid 1mg/ml

60 mLs/30 days

36 mL/30 days

hydromorphone tablet 2mg

30 tablets/30 days

18 tablets/30 days

hydromorphone tablet 4mg

15 tablets/30 days

9 tablets/30 days

hydromorphone tablet 8mg

5 tablets/30 days

3 tablets/30 days

hydromorphone liquid 1mg/ml

60 mLs/30 days

36 mL/30 days

hydromorphone tablet 2mg

30 tablets/30 days

18 tablets/30 days

hydromorphone tablet 4mg

15 tablets/30 days

9 tablets/30 days

hydromorphone tablet 8mg

5 tablets/30 days

3 tablets/30 days

ibudone tablet 5-200mg

25 tablets/30 days

15 tablets/30 days

levorphanol tablet 2mg

10 tablets/30 days

6 tablets/30 days

lorcet tablet 5-325mg

40 tablets/30 days

6 tablets/30 days

lorcet plus tablet 7.5-325

30 tablets/30 days

N/A

lorcet hd tablet 10-325mg

25 tablets/30 days

N/A

meperidine tablet 50mg

30 tablets/30 days

30 tablets/30 days

MEPERIDINE SOLUTION 50MG/5ML

150 mLs/30 days

150 mL/30 days

meperidine tablet 100mg

15 tablets/30 days

15 tablets/30 days

methadone solution 5mg/5ml

10 mLs/30 days

N/A

methadone solution 10mg/5ml

5 mLs/30 days

N/A

methadone tablet 5mg

60 tablets/30 days

N/A

methadone tablet 10mg

30 tablets/30 days

N/A

morphine sulfate solution 10/0.5ml

10 mLs/30 days

N.A

morphine sulfate solution 10mg/5ml

125 mLs/30 days

75 mL/30 days

morphine sulfate solution 100/5ml

10 mLs/30 days

N/A

morphine sulfate solution 20mg/5ml

60 mLs/30 days

36 mL/30 days

morphine sulfate solution 20mg/ml

10 mLs/30 days

6 mL/30 days

MORPHINE SULFATE TABLET 15MG

15 tablets/30 days

N/A

MORPHINE SULFATE TABLET 30MG

5 tablets/30 days

N/A

NUCYNTA TABLET 50MG

10 tablets/30 days

6 tablets/30 days

NUCYNTA TABLET 75MG

5 tablets/30 days

3 tablets/30 days

NUCYNTA TABLET 100MG

5 tablets/30 days

3 tablets/30 days

oxycodone/acetaminophen tablet 2.5-325

60 tablets/30 days

36 tablets/30 days

oxycodone/acetaminophen tablet 5-325mg

30 tablets/30 days

18 tablets/30 days

oxycodone/acetaminophen tablet 7.5-325

20 tablets/30 days

12 tablets/30 days

oxycodone/acetaminophen tablet 10-325mg

15 tablets/30 days

9 tablets/30 days

oxycodone/aspirin tablet

30 tablets/30 days

18 tablets/30 days

OXYCODONE/IBUPROFEN TABLET 5-400MG

20 tablets/30 days

12 tablets/30 days

oxycodone concentrate 10/0.5ml

5 mLs/30 days

N/A

oxycodone concentrate 100/5ml

5 mLs/30 days

N/A

oxycodone solution 5mg/5ml

165 mLs/30 days

99 mL/30 days

oxycodone concentrate 10/0.5ml

5 mLs/30 days

N/A

oxycodone tablet 5mg

30 tablets/30 days

18 tablets/30 days

oxycodone tablet 10mg

15 tablets/30 days

9 tablets/30 days

oxycodone tablet 15mg

10 tablets/30 days

6 tablets/30 days

oxycodone tablet 20mg

5 tablets/30 days

3 tablets/30 days

oxycodone tablet 30mg

5 tablets/30 days

3 tablets/30 days

OXYCODONE/ SOLUTION APAP

100 mLs/30 days

60 mL/30 days

tramadol hcl tablet 50mg

50 tablets/30 days

30 tablets/30 days

VERDROCET TABLET 2.5-325

60 tablets/30 days

N/A

xylon tablet 10-200mg

25 tablets/30 days

N/A


1Specialty

2Limited Distribution

3Split Fill