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
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