Value Plus - 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)

ABSTRAL SUBLINGUAL 100MCG

120 Tablets/30 Days

ABSTRAL SUBLINGUAL 200MCG

120 Tablets/30 Days

ABSTRAL SUBLINGUAL 300MCG

120 Tablets/30 Days

ABSTRAL SUBLINGUAL 400MCG

120 Tablets/30 Days

ABSTRAL SUBLINGUAL 600MCG

120 Tablets/30 Days

ABSTRAL SUBLINGUAL 800MCG

120 Tablets/30 Days

ACTIQ LOZENGE 200MCG

120 Lozenges/30 Days

ACTIQ LOZENGE 400MCG

120 Lozenges/30 Days

ACTIQ LOZENGE 600MCG

120 Lozenges/30 Days

ACTIQ LOZENGE 800MCG

120 Lozenges/30 Days

ACTIQ LOZENGE 1200MCG

120 Lozenges/30 Days

ACTIQ LOZENGE 1600MCG

120 Lozenges/30 Days

FENTANYL CITRATE TABLET 100MCG

120 Tablets/30 Days

FENTANYL CITRATE TABLET 200MCG

120 Tablets/30 Days

FENTANYL CITRATE TABLET 400MCG

120 Tablets/30 Days

FENTANYL CITRATE TABLET 600MCG

120 Tablets/30 Days

FENTANYL CITRATE TABLET 800MCG

120 Tablets/30 Days

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

FENTORA TABLET 100MCG

120 Tablets/30 Days

FENTORA TABLET 200MCG

120 Tablets/30 Days

FENTORA TABLET 400MCG

120 Tablets/30 Days

FENTORA TABLET 600MCG

120 Tablets/30 Days

FENTORA TABLET 800MCG

120 Tablets/30 Days

LAZANDA SPRAY 100MCG

30 Bottles/30 Days

LAZANDA SPRAY 300MCG

30 Bottles /30 Days

LAZANDA SPRAY 400MCG

30 Bottles/30 Days

SUBSYS SPRAY 100MCG

120 Sprays/30 Days

SUBSYS SPRAY 200MCG

120 Sprays/30 Days

SUBSYS SPRAY 400MCG

120 Sprays/30 Days

SUBSYS SPRAY 600MCG

120 Sprays/30 Days

SUBSYS SPRAY 800MCG

120 Sprays/30 Days

SUBSYS SPRAY 1200MCG

240 Sprays/30 Days

SUBSYS SPRAY 1600MCG

240 Sprays/30 Days

Opioids Extended Release (ER)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

ARYMO ER TABLET 15MG

60 Tablets/30 Days

ARYMO ER TABLET 30MG

30 Tablets/30 Days

ARYMO ER TABLET 60MG

0

BELBUCA MIS 75MCG

60 Films/30 Days

BELBUCA MIS 150MCG

60 Films/30 Days

BELBUCA MIS 300MCG

60 Films/30 Days

BELBUCA MIS 450MCG

60 Films/30 Days

BELBUCA MIS 600MCG

60 Films/30 Days

BELBUCA MIS 750MCG

60 Films/30 Days

BELBUCA MIS 900MCG

30 Films/30 Days

buprenorphine dis 5mcg/hr

4 Systems/30 Days

buprenorphine dis 10mcg/hr

4 Systems/30 Days

buprenorphine dis 15mcg/hr

4 Systems/30 Days

buprenorphine dis 20mcg/hr

4 Systems/30 Days

buprenorphine dis 7.5/hr

4 Systems/30 Days

BUTRANS DIS 5MCG/HR

4 Systems/30 Days

BUTRANS DIS 7.5/HR

4 Systems/30 Days

BUTRANS DIS 10MCG/HR

4 Systems/30 Days

BUTRANS DIS 15MCG/HR

4 Systems/30 Days

BUTRANS DIS 20MCG/HR

4 Systems/30 Days

CONZIP CAPSULE 100MG

30 Capsules/30 Days

CONZIP CAPSULE 200MG

30 Capsules/30 Days

CONZIP CAPSULE 300MG

30 Capsules/30 Days

DURAGESIC DIS 12MCG/HR

10 Patches/30 Days

DURAGESIC DIS 25MCG/HR

0

DURAGESIC DIS 50MCG/HR

0

DURAGESIC DIS 75MCG/HR

0

DURAGESIC DIS 100MCG/HR

0

EMBEDA CAPSULE 20-0.8MG

30 Capsules/30 Days

EMBEDA CAPSULE 30-1.2MG

30 Capsules/30 Days

EMBEDA CAPSULE 50-2MG

30 Capsules/30 Days

EMBEDA CAPSULE 60-2.4MG

0

EMBEDA CAPSULE 80-3.2MG

0

EMBEDA CAPSULE 100-4MG

0

EXALGO TABLET 8MG

30 Tablets/30 Days

EXALGO TABLET 12MG

30 Tablets/30 Days

EXALGO TABLET 16MG

0

EXALGO TABLET 32MG

0

fentanyl dis 12mcg/hr

10 Patches/30 Days

fentanyl dis 25mcg/hr

0

fentanyl dis 37.5mcg/hr

0

fentanyl dis 50mcg/hr

0

fentanyl dis 62.5mcg/hr

0

fentanyl dis 75mcg/hr

0

fentanyl dis 87.5mcg/hr

0

fentanyl dis 100mcg/hr

0

hydrocodone capsule 10mg er

60 Capsules/30 Days

hydrocodone capsule 15mg er

60 Capsules/30 Days

hydrocodone capsule 20mg er

60 Capsules/30 Days

hydrocodone capsule 30mg er

30 Capsules/30 Days

hydrocodone capsule 40mg er

30 Capsules/30 Days

hydrocodone capsule 50mg er

30 Capsules/30 Days

hydromorphone tablet 8mg er

30 Tablets/30 Days

hydromorphone tablet 12mg er

30 Tablets/30 Days

hydromorphone tablet 16mg er

0

hydromorphone tablet 32mg er

0

HYSINGLA ER TABLET 20 MG

30 Tablets/30 Days

HYSINGLA ER TABLET 30 MG

30 Tablets/30 Days

HYSINGLA ER TABLET 40 MG

30 Tablets/30 Days

HYSINGLA ER TABLET 60 MG

0

HYSINGLA ER TABLET 80 MG

0

HYSINGLA ER TABLET 100 MG

0

HYSINGLA ER TABLET 120 MG

0

KADIAN CAPSULE 10MG ER

30 Capsules/30 Days

KADIAN CAPSULE 20MG ER

30 Capsules/30 Days

KADIAN CAPSULE 30MG ER

30 Capsules/30 Days

KADIAN CAPSULE 40MG ER

30 Capsules/30 Days

KADIAN CAPSULE 50MG ER

30 Capsules/30 Days

KADIAN CAPSULE 60MG ER

0

KADIAN CAPSULE 80MG ER

0

KADIAN CAPSULE 100MG ER

0

KADIAN CAPSULE 200MG ER

0

MORPHABOND TABLET 15MG ER

60 Tablets/30 Days

MORPHABOND TABLET 30MG ER

30 Tablets/30 Days

MORPHABOND TABLET 60MG ER

0

MORPHABOND TABLET 100MG ER

0

morphine sulfate tablet 15mg

15 Tablets/30 Days

morphine sulfate tablet 30mg

5 Tablets/30 Days

morphine sulfate capsule 10mg er

30 Capsules/30 Days

morphine sulfate capsule 20mg er

30 Capsules/30 Days

morphine  sulfate capsule 30mg er

30 Capsules/30 Days

morphine  sulfate capsule 40mg er

30 Capsules/30 Days

morphine  sulfate capsule 50mg er

30 Capsules/30 Days

morphine  sulfate capsule 60mg er

0

morphine  sulfate capsule 80mg er

0

morphine sulfate capsule 100mg er

0

MORPHINE SULFATE CAPSULE 30MG ER

30 Capsules/30 Days

MORPHINESULFATE CAPSULE 45MG ER

30 Capsules/30 Days

MORPHINE SULFATE CAPSULE 60MG ER

0

MORPHINE SULFATE CAPSULE 75MG ER

0

MORPHINE SULFATE CAPSULE 90MG ER

0

MORPHINE SULFATE CAPSULE 120MG ER

0

morphine sulfate tablet 100mg cr

0

morphine  sulfate tablet 15mg er

60 Tablets/30 Days

morphine  sulfate tablet 30mg er

30 Tablets/30 Days

morphine  sulfate tablet  60mg er

0

morphine sulfate tablet 100mg er

0

morphine sulfate tablet 200mg er

0

MS CONTIN TABLET 15MG ER

60 Tablets/30 Days

MS CONTIN TABLET 30MG ER

30 Tablets/30 Days

MS CONTIN TABLET 60MG ER

0

MS CONTIN TABLET 100MG ER

0

MS CONTIN TABLET 200MG ER

0

NUCYNTA ER TABLET 50MG

60 Tablets/30 Days

NUCYNTA ER TABLET 100MG

30 Tablets/30 Days

NUCYNTA ER TABLET 150MG

0

NUCYNTA ER TABLET 200MG

0

NUCYNTA ER TABLET 250MG

0

OPANA ER TABLET 5MG

60 Tablets/30 Days

OPANA ER TABLET 7.5MG

60 Tablets/30 Days

OPANA ER TABLET 10MG

30 Tablets/30 Days

OPANA ER TABLET 15MG

30 Tablets/30 Days

OPANA ER TABLET 20MG

0

OPANA ER TABLET 30MG

0

OPANA ER TABLET 40MG

0

OXYCODONE TABLET 10MG ER

60 Tablets/30 Days

OXYCODONE TABLET 15MG ER

60 Tablets/30 Days

OXYCODONE TABLET 20MG ER

30 Tablets/30 Days

OXYCODONE TABLET 30MG ER

30 Tablets/30 Days

OXYCODONE TABLET 40MG ER

0

OXYCODONE TABLET 60MG ER

0

OXYCODONE TABLET 80MG ER

0

OXYCONTIN TABLET 10MG CR

60 Tablets/30 Days

OXYCONTIN TABLET 15MG CR

60 Tablets/30 Days

OXYCONTIN TABLET 20MG CR

30 Tablets/30 Days

OXYCONTIN TABLET 30MG CR

30 Tablets/30 Days

OXYCONTIN TABLET 40MG CR

0

OXYCONTIN TABLET 60MG CR

0

OXYCONTIN TABLET 80MG CR

0

OXYMORPHONE TABLET 5MG ER

60 Tablets/30 Days

OXYMORPHONE TABLET 7.5MG ER

60 Tablets/30 Days

OXYMORPHONE TABLET 10MG ER

30 Tablets/30 Days

OXYMORPHONE TABLET 15MG ER

30 Tablets/30 Days

OXYMORPHONE TABLET 20MG ER

0

OXYMORPHONE TABLET 30MG ER

0

OXYMORPHONE TABLET 40MG ER

0

TRAMADOL HCL CAPSULE 150MG ER

30 Capsules/30 Days

TRAMADOL HCL CAPSULE ER 100MG

30 Capsules/30 Days

TRAMADOL HCL CAPSULE ER 200MG

30 Capsules/30 Days

TRAMADOL HCL CAPSULE ER 300MG

30 Capsules/30 Days

tramadol hcl tablet 100mg er

30 Tablets/30 Days

tramadol hcl tablet 200mg er

30 Tablets/30 Days

tramadol hcl tablet 300mg er

30 Tablets/30 Days

XTAMPZA ER CAPSULE 9MG

60 Capsules/30 Days

XTAMPZA ER CAPSULE 13.5MG

60 Capsules/30 Days

XTAMPZA ER CAPSULE 18MG

30 Capsules/30 Days

XTAMPZA ER CAPSULE 27MG

30 Capsules/30 Days

XTAMPZA ER CAPSULE 36MG

0

ZOHYDRO ER CAPSULE 10MG

60 Capsules/30 Days

ZOHYDRO ER CAPSULE 15MG

60 Capsules/30 Days

ZOHYDRO ER CAPSULE 20MG

60 Capsules/30 Days

ZOHYDRO ER CAPSULE 30MG

30 Capsules/30 Days

ZOHYDRO ER CAPSULE 40MG

30 Capsules/30 Days

ZOHYDRO ER CAPSULE 50MG

30 Capsules/30 Days

Opioids Immediate Release (IR)

Drug Name(s)

Adult Quantity Limit – 5 Days

Child Quantity Limit – 3 Days

ACETAMINOPHEN-CAFFEINE DIHYDROCODEINE CAPSULE

50 Capsules/30 Days

30 capsules/30 days

ACETAMINOPHEN/CAFFEINE DIHYDROCODEINE TABLET

50 Tablets/30 Days

30 capsules/30 days

acetaminophen/caffeine dihydrocodeine tablet

50 Capsules/30 Days

N/A

acetaminophen/codeine solution 120-12/5

450 mLs/30 Days

270 mL/30 days

acetaminophen/codeine tablet 300-15mg

30 Tablets/30 Days

N/A

acetaminophen/codeine tablet 300-30mg

30 Tablets/30 Days

N/A

acetaminophen/codeine tablet 300-60mg

25 Tablets/30 Days

N/A

butorphanol solution 10mg/ml

1 Bottle/30 Days

0 mL/30 days

CODEINE SULFATE TABLET 15MG

30 Tablets/30 Days

18 tablets/30 days

CODEINE SULFATE TABLET 30MG

30 Tablets/30 Days

18 tablets/30 days

CODEINE SULFATE TABLET 60MG

25 Tablets/30 Days

15 tablets/30 days

DEMEROL TABLET 100MG

15 Tablets/30 Days

N/A

DILAUDID LIQUID 1MG/ML

60 mLs/30 Days

36 mL/30 days

DILAUDID TABLET 2MG

30 Tablets/30 Days

18 tablets/30 days

DILAUDID TABLET 4MG

15 Tablets/30 Days

9 tablets/30 days

DILAUDID TABLET 8MG

5 Tablets/30 Days

3 tablets/30 days

DOLOPHINE TABLET 5MG

60 Tablets/30 Days

N/A

DOLOPHINE TABLET 10MG

30 Tablets/30 Days

N/A

dvorah tablet

50 Tablets/30 Days

N/A

endocet tablet 2.5-325

60 Tablets/30 Days

36 tablets/30 days

endocet tablet 5-325mg

30 Tablets/30 Days

18 tablets/30 days

endocet tablet 7.5-325

20 Tablets/30 Days

12 tablets/30 days

endocet tablet 10-325mg

15 Tablets/30 Days

9 tablets/30 days

hydrocodone/acetaminophen tablet 2.5-325mg

60 Tablets/30 Days

36 tablets/30 days

hydrocodone/acetaminophen tablet 5-325mg

40 Tablets/30 Days

24 tablets/30 days

hydrocodone/acetaminophen tablet 7.5-325mg

30 Tablets/30 Days

18 tablets/30 days

hydrocodone/acetaminophen tablet 10-325mg

25 Tablets/30 Days

15 tablets/30 days

hydrocodone/acetaminophen solution 7.5-325mg

450 mLs/30 Days

270 mL/30 days

HYDROCODONE/ACETAMINOPHEN SOLUTION 10-325MG

375 mLs/30 Days

225 mL/30 days

hydrocodone/acetaminophen tablet 5-300mg

40 Tablets/30 Days

24 tablets/30 days

hydrocodone/acetaminophen tablet 7.5-300 mg

30 Tablets/30 Days

18 tablets/30 days

hydrocodone/acetaminophen tablet 10-300mg

25 Tablets/30 Days

15 tablets/30 days

hydrocodone/ibuprofen tablet 5-200mg

25 Tablets/30 Days

15 tablets/30 days

hydrocodone/ibuprofen tablet 7.5-200mg

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 SUPPOSITORY 3MG

20 Suppositories/30 Days

N/A

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

IBUDONE TABLET 10-200MG

25 Tablets/30 Days

15 tablets/30 days

levorphanol tablet 2mg

10 Tablets/30 Days

6 tablets/30 days

levorphanol tablet 3mg

10 Tablets/30 Days

6 tablets/30 days

lorcet hd tablet 10-325mg

25 Tablets/30 Days

N/A

lorcet plus tablet 7.5-325

30 Tablets/30 Days

N/A

lorcet tablet 5-325mg

40 Tablets/30 Days

N/A

LORTAB ELIXER 10-300MG

338 mLs/30 Days

N/A

MEPERIDINE SOLUTION 50MG/5ML

150 mLs/30 Days

150 mL/30 days

meperidine tablet 50mg

30 Tablets/30 Days

30 tablets/30 days

meperidine tablet 100mg

15 Tablets/30 Days

15 tablets/30 days

METHADONE SOLUTION 5MG/5ML

300 mLs/30 Days

N/A

METHADONE SOLUTION 10MG/5ML

150 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 10mg/5ml

125 mLs/30 Days

75 mL/30 days

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 SUPPOSITORY 5MG

50 Suppositories/30 Days

N/A

MORPHINE SULFATE SUPPOSITORY 10MG

25 Suppositories/30 Days

N/A

MORPHINE SULFATE SUPPOSITORY 20MG

10 Suppositories/30 Days

N/A

MORPHINE SULFATE SUPPOSITORY 30MG

5 Suppositories/30 Days

N/A

MORPHINE SULFATE TABLET 15MG

15 Tablets/30 Days

9 tablets/30 days

MORPHINE SULFATE TABLET 30MG

5 Tablets/30 Days

3 tablets/30 days

NORCO TABLET 5-325MG

40 Tablets/30 Days

24 tablets/30 days

NORCO TABLET 7.5-325

30 Tablets/30 Days

18 tablets/30 days

NORCO TABLET 10-325MG

25 Tablets/30 Days

15 tablets/30 days

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

OPANA TABLET 5MG

15 Tablets/30 Days

9 tablets/30 days

OPANA TABLET 10MG

5 Tablets/30 Days

3 tablets/30 days

OXAYDO TABLET 5MG

30 Tablets/30 Days

18 tablets/30 days

OXAYDO TABLET 7.5MG

20 Tablets/30 Days

12 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/IBUPRIOFEN TABLET 5-400MG

20 Tablets/30 Days

12 tablets/30 days

oxycodone capsule 5mg

30 Capsules/30 Days

18 capsules/30 days

oxycodone concentrate 20/ml

5 mLs/30 Days

3 mL/30 days

oxycodone solution 5mg/5ml

165 mLs/30 Days

99 mL/30 days

oxycodone tablet 5mg

30 Tablets/30 Days

18 capsules/30 days

oxycodone tablet 7.5mg

20 Tablets/30 Days

12 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 ACETAMINOPHEN

100 mLs/30 Days

60 mL/30 days

oxymorphone tablet hcl 5mg

15 Tablets/30 Days

9 tablets/30 days

oxymorphone tablet hcl 10mg

5 Tablets/30 Days

3 tablets/30 days

panlor tablet 325-30

50 Capsules/30 Days

N/A

pentazocine/naloxone tablet 50-0.5mg

10 Tablets/30 Days

6 tablets/30 days

PERCOCET TABLET 2.5-325

60 Tablets/30 Days

36 tablets/30 days

PERCOCET TABLET 5-325MG

30 Tablets/30 Days

18 tablets/30 days

PERCOCET TABLET 7.5-325

20 Tablets/30 Days

12 tablets/30 days

PERCOCET TABLET 10-325MG

15 Tablets/30 Days

9 tablets/30 days

PRIMLEV TABLET 5-300MG

30 Tablets/30 Days

18 tablets/30 days

PRIMLEV TABLET 7.5-300

20 Tablets/30 Days

12 tablets/30 days

PRIMLEV TABLET 10-300MG

15 Tablets/30 Days

9 tablets/30 days

ROXICODONE TABLET 5MG

30 Tablets/30 Days

18 tablets/30 days

ROXICODONE TABLET 15MG

10 Tablets/30 Days

6 tablets/30 days

ROXICODONE TABLET 30MG

5 Tablets/30 Days

3 tablets/30 days

ROXYBOND TABLET 5MG

30 Tablets/30 Days

18 tablets/30 days

tramadol hcl tablet 50mg

50 Tablets/30 Days

30 tablets/30 days

tramadol/acetaminophen tablet 37.5-325

40 Tablets/30 Days

24 tablets/30 days

TREZIX CAPSULE

50 Capsules/30 Days

30 capsules/30 days

TYLENOL/CODEINE TABLET #2

30 Tablets/30 Days

18 tablets/30 days

TYLENOL/CODEINE TABLET #3

30 Tablets/30 Days

18 tablets/30 days

TYLENOL/CODEINE TABLET #4

25 Tablets/30 Days

15 tablets/30 days

ULTRACET TABLET 37.5-325

40 Tablets/30 Days

24 tablets/30 days

ULTRAM TABLET 50MG

50 Tablets/30 Days

30 tablets/30 days

VERDROCET TABLET 2.5-325

60 Tablets/30 Days

N/A

vicodin es tablet 7.5-300

30 Tablets/30 Days

N/A

vicodin hp tablet 10-300mg

25 Tablets/30 Days

N/A

vicodin tablet 5-300mg

40 Tablets/30 Days

N/A

xylon tablet 10-200mg

25 Tablets/30 Days

15 tablets/30 days


1Specialty

2Limited Distribution

3Split Fill