Value Plus - Opioid (QLL) 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

acetaminophen /codeine sol 120-12/5

450 ML/30 days

270 ML/30 days

acetaminophen /codeine tab 300-15mg

30 tablets/30 days

18 tablets/30 days

acetaminophen /codeine tab 300-30mg

30 tablets/30 days

18 tablets/30 days

acetaminophen /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 sulfate tab 30mg

30 tablets/30 days

18 tablets/30 days

codeine/acetaminophen tab 30-300mg

30 tablets/30 days

18 tablets/30 days

codeine/acetaminophen tab 60-300mg

25 tablets/30 days

15 tablets/30 days

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 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 37.5mcg

0 patches/month

N/A

fentanyl dis 50mcg/hr

0 patches/month

N/A

fentanyl dis 62.5mcg

0 patches/month

N/A

fentanyl dis 75mcg/hr

0 patches/month

N/A

fentanyl dis 87.5mcg

0 patches/month

N/A

fentanyl ot loz 1200mcg

120 LOZNGS / 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/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/acetaminophen sol 7.5-325

450 ML/30 days

270 ML/30 days

hydrocodone/acetaminophen tab 10-300mg

25 tablets/30 days

15 tablets/30 days

hydrocodone/acetaminophen tab 10-325mg

25 tablets/30 days

15 tablets/30 days

hydrocodone/acetaminophen tab 5-300mg

40 tablets/30 days

24 tablets/30 days

hydrocodone/acetaminophen tab 5-325mg

40 tablets/30 days

24 tablets/30 days

hydrocodone/acetaminophen tab 7.5-300

30 tablets/30 days

18 tablets/30 days

hydrocodone/acetaminophen 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

HYDROCODONE CAP 10MG ER

60 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 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 30mg er

30 capsules/30 days

N/A

HYDROCODONE CAP 40MG 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 50mg er

30 capsules/30 days

N/A

hydrocodone tab 100mg er

0 tablets/30 days

N/A

hydrocodone tab 120mg er

0 tablets/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

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

KADIAN CAP 200MG ER

0 capsules/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

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 sulfate cap 100mg er

0 capsules/30 days

N/A

morphine sulfate cap 10mg er

30 capsules/30 days

N/A

morphine sulfate cap 20mg er

30 capsules/30 days

N/A

morphine sulfate cap 30mg er

30 capsules/30 days

N/A

morphine sulfate cap 50mg er

30 capsules/30 days

N/A

morphine sulfate cap 60mg er

0 capsules/30 days

N/A

morphine sulfate cap 80mg er

0 capsules/30 days

N/A

morphine sulfate sol 10/0.5ml

15 ML/30 days

15 ML/30 days

morphine sulfate sol 100/5ml

15 ML/30 days

15 ML/30 days

morphine sulfate sol 10mg/5ml

125 ML/30 days

75 ML/30 days

morphine sulfate sol 20mg/5ml

60 ML/30 days

36 ML/30 days

morphine sulfate sol 20mg/ml

15 ML/30 days

15 ML/30 days

morphine sulfate tab 100mg cr

0 tablets/30 days

N/A

morphine sulfate tab 100mg er

0 tablets/30 days

N/A

morphine sulfate tab 15mg

15 tablets/30 days

9 tablets/30 days

morphine sulfate tab 15mg er

60 tablets/30 days

N/A

morphine sulfate tab 200mg er

0 tablets/30 days

N/A

morphine sulfate tab 30mg

5 tablets/30 days

3 tablets/30 days

morphine sulfate tab 30mg er

30 tablets/30 days

N/A

morphine sulfate tab 60mg er

0 tablets/30 days

N/A

oxycodone/ acetaminophen tab 10-325mg

15 tablets/30 days

9 tablets/30 days

oxycodone/ acetaminophen tab 2.5-325

60 tablets/30 days

36 tablets/30 days

oxycodone/ acetaminophen tab 5-325mg

30 tablets/30 days

18 tablets/30 days

oxycodone/ acetaminophen tab 7.5-325

20 tablets/30 days

12 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 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 5mg

30 tablets/30 days

18 tablets/30 days

oxymorphone tab hcl 10mg

5 tablets/30 days

3 tablets/30 days

oxymorphone tab hcl 5mg

15 tablets/30 days

9 tablets/30 days

pentazocine/naloxone tab 50-0.5mg

10 tablets/30 days

6 tablets/30 days

tramadol/acetaminophen tab 37.5-325

40 tablets/30 days

24 tablets/30 days

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

Complementary Content
${loading}