Category Filter
- Advanced Imaging
- Autism Spectrum Mandate
- Behavioral Health
- Blue Advantage Policies
- Chronic Condition Management
- Genetic Testing
- HelpScript Program
- Hemophilia Drugs
- Medical Policies
- Pre-Service Review (Predetermination/Precertification)
- Provider-Administered Drug Policies
- Radiation Therapy
- Self-Administered Drug Policies
- Transgender Services
Asset Publisher
Opioids Immediate Release (IR) Quantity Limit Program Summary
Policy Number: PH-91117
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
04-01-2025 |
|
FDA LABELED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Apadaz®, Benzhydrocodone/Acetaminophen Tablet |
Short-term (no more than 14 days) management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
|
|
6 |
butorphanol Nasal spray* |
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
7 |
Codeine Tablet* |
Management of mild to moderate pain, where treatment with an opioid is appropriate and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
8 |
Meperidine Tablet* Solution |
Management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. This agent should not be used for the treatment of chronic pain. Use for an extended period of time may increase the risk of toxicity (e.g., seizures) from the accumulation of the meperidine metabolite, normeperidine. |
*generic available |
18 |
Dilaudid® (hydromorphone) Tablet* Liquid* |
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
9 |
Methadose, Methadone™ Tablet* Soluble tablet* Solution* Concentrate* |
Management of severe and persistent pain that requires an extended treatment period with a daily opioid analgesic and for which alternative treatment options are inadequate Limitations of Use:
|
*generic available |
19,20 |
Fioricet w/Codeine® (butalbital/acetaminophen/caffeine/codeine) Capsule* |
Management of the symptom complex of tension (or muscle contraction) headache when non-opioid analgesic and alternative treatments are inadequate Limitations for Use:
|
*generic available |
11 |
butalbital/aspirin/caffeine/codeine Capsule* |
Management of the symptom complex of tension (or muscle contraction) headache when non-opioid analgesic and alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
12 |
Hydrocodone/Ibuprofen Tablet* |
Short-term management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
15 |
levorphanol Tablet* |
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
16 |
Lortab® (hydrocodone/acetaminophen) Solution* Tablet* |
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
17,22 |
Morphine Sulfate Tablet* Concentrate* Solution* |
Management of:
Limitations of Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
21 |
Nalocet®, Oxycodone/Acetaminophen, Percocet®, Prolate® Tablet* Solution |
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
26,32,33 |
Nucynta® (tapentadol) Tablet |
Management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate in adults and pediatric patients aged 6 years and older with a body weight of at least 40 kg. Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
|
23 |
Oxaydo®, Roxicodone®, Roxybond™ (oxycodone) Capsule* Tablet* Solution* Concentrate* |
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Oxycodone Hydrochloride Oral Solution 100 mg per 5 mL (20 mg/mL) is indicated for the relief of pain in opioid-tolerant adults. Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
24,25,35,41 |
oxymorphone Tablet* |
Management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
30 |
pentazocine/naloxone Tablet* |
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
31 |
Seglentis (celecoxib/tramadol) Tablet |
Management of acute pain in adults that is severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
|
36 |
Trezix™, Acetaminophen/Caffeine/Dihydrocodeine Capsule |
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
|
|
37 |
Tylenol® w/Codeine, Acetaminophen/Codeine Tablet* Oral solution* |
Management of mild to moderate pain, where treatment with an opioid is appropriate and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
5,38 |
tramadol/acetaminophen Tablet* |
Management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations of Use:
|
*generic available |
39 |
Odolo™, Tramadol (tramadol) Tablet* Oral solution |
Management of pain in adults that is severe enough to require an opioid analgesic and for which alternative treatments are inadequate Limitations for Use:
This agent should not be used for an extended period of time unless the pain remains severe enough to require an opioid analgesic and for which alternative treatment options continue to be inadequate. |
*generic available |
34,40 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
CLINICAL RATIONALE |
The Centers for Disease Control and Prevention (CDC) guidelines define acute pain as pain with abrupt onset and caused by an injury or other process that is not ongoing. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.(1)
Use of tramadol or codeine containing products in pediatric patients has caused life-threatening respiratory depression, with some of the reported cases occurring post-tonsillectomy and/or adenoidectomy. Ultra-rapid metabolizers are at increased risk of life-threatening respiratory depression due to a CYP2D6 polymorphism. Use in children under 12 years of age is contraindicated for these products, and for those between the ages of 12 and 18 years when used for post-operative pain management following tonsillectomy and/or adenoidectomy.(3)
The CDC defines chronic pain as pain that continues or is expected to continue more than three months or past the time of normal tissue healing. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The Food and Drug Administration (FDA) modified labeling of ER/LA opioids, indicating they should be reserved for management of severe, continuous pain requiring daily, around-the-clock, long term opioid treatment. The CDC indicates ER/LA opioids should be reserved for severe pain and should be considered only for patients who have received immediate-release opioids daily for at least 1 week. Assessment should be done to determine if continued opioid therapy is needed.(1)
The American Society of Interventional Pain Physicians (ASIPP) 2023 Comprehensive Evidence-Based Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain states that there is similar effectiveness for long and short-acting opioids, with increased adverse consequences of long-acting opioids. High doses of long-acting agents should only be used in limited circumstances wherein the management of severe, intractable pain is not responsive or mitigated by short-acting opioids or moderate doses of long-acting opioids. The guidelines recommend the following for the treatment of chronic non-cancer pain:(2)
The 2022 CDC guidelines for Prescribing Opioids for Pain recommend the following for prescribing opioids for acute, subacute, and chronic pain:(1)
The CDC guideline for opioid prescribing note that patients with cancer, sickle cell disease, and patients receiving palliative or end of life care are exempt from these recommendations. The guideline also states that although identification of an opioid use disorder can alter the expected benefits and risks of opioid therapy for pain, patients with co-occurring pain and substance use disorder require ongoing pain management that maximizes benefits relative to risks. Clinicians should continue to use non-pharmacologic and non-opioid pharmacologic pain treatments as appropriate and consider consulting a pain specialist as needed to provide optimal pain management.(1) |
REFERENCES
Number |
Reference |
1 |
Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. Accessed at: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm |
2 |
Manchikanti L, Kaye AM, Knezevic NN, et al. Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician Journal. 2023;26:S7-S126. |
3 |
FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. January 2018. Assessed August 2024. |
4 |
Reference no longer used. |
5 |
Acetaminophen/codeine solution prescribing information. Akorn. November 2022. |
6 |
Apadaz prescribing information. KVK Tech Inc. March 2021. |
7 |
butorphanol tartrate nasal solution prescribing information. Apotex Corp. November 2023. |
8 |
Codeine prescribing information. Hikma Pharmaceuticals USA Inc. December 2023. |
9 |
Dilaudid prescribing information. Rhodes Pharmaceuticals. January 2024 |
10 |
Reference no longer used. |
11 |
Fioricet with Codeine prescribing information. Actavis Pharma, Inc. March 2021. |
12 |
Butalbital, Aspirin, Caffeine, Codeine prescribing information. Breckenridge Pharmaceutical. March 2024. |
13 |
Reference no longer used. |
14 |
Reference no longer used. |
15 |
Hydrocodone/Ibuprofen prescribing information. Amneal Pharmaceuticals, LLC. January 2024. |
16 |
levorphanol prescribing information. Lannett Company, Inc. June 2024. |
17 |
Lortab prescribing information. Akorn, Inc. September 2022. |
18 |
Meperidine prescribing information. Hikma Pharmaceuticals USA Inc. May 2024. |
19 |
Methadone prescribing information. Hikma Pharmaceuticals USA Inc. January 2024. |
20 |
Methadose prescribing information. VistaPharm. August 2024. |
21 |
Morphine Sulfate prescribing information. Hikma Pharmaceuticals USA Inc. December 2023. |
22 |
Hydrocodone/Acetaminophen tablet prescribing information. Amneal Pharmaceuticals, LLC. January 2024. |
23 |
Nucynta prescribing information. Collegium Pharm, Inc. December 2023. |
24 |
Oxaydo prescribing information. Zyla Life Sciences US Inc. April 2024. |
25 |
oxycodone prescribing information. ANI Pharmaceuticals Inc. May 2024. |
26 |
Nalocet prescribing information. Forte Bio-Pharma LLC. January 2024. |
27 |
Reference no longer used. |
28 |
Reference no longer used. |
29 |
Reference no longer used. |
30 |
oxymorphone prescribing information. Hikma Pharmaceuticals. December 2023. |
31 |
pentazocine/naloxone prescribing information. Actavis Pharma, Inc. November 2023. |
32 |
Percocet prescribing information. Endo Pharmaceuticals Inc. June 2024. |
33 |
Prolate prescribing information. Forte Bio-Pharma LLC. January 2024. |
34 |
Qdolo prescribing information. Athena Bioscience, LLC. December 2023. |
35 |
Roxicodone prescribing information. Specgx LLC. April 2024. |
36 |
Seglentis prescribing information. Kowa Pharmaceuticals America, Inc. August 2024. |
37 |
Trezix prescribing information. Proficient Rx LP. May 2022. |
38 |
Tylenol with Codeine prescribing information. A-S Medication Solutions. April 2019. |
39 |
tramadol/acetaminophen prescribing information. Amneal Pharmaceuticals of New York LLC. January 2024. |
40 |
tramadol oral solution prescribing information Janssen Pharms. Teva Pharmaceuticals USA Inc. December 2023 |
41 |
Roxybond prescribing information. Protega Pharms. Arpil 2024. |
OBJECTIVE
The intent of the Opioids IR quantity limit is to encourage FDA approved dosing regimen. Requests for larger quantities will be approved upon review. The program will also check for appropriate age for requests for products containing tramadol, dihydrocodeine, and codeine. Requests for these agents will be limited to patients 12 years of age and older, and patients 12 years to 18 years will be restricted from use for post-operative pain management following a tonsillectomy and/or adenoidectomy.
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
|
Acetaminophen w/ Codeine Tab 300-15 MG |
300-15 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
|
Acetaminophen w/ Codeine Tab 300-30 MG |
300-30 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
|
Acetaminophen w/ Codeine Tab 300-60 MG |
300-60 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Acetaminophen-Caffeine-Dihydrocodeine Tab 325-30-16 MG |
|
300 |
Tablets |
30 |
DAYS |
|
|
|
|
Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30 MG |
50-325-40-30 MG |
180 |
Capsules |
30 |
DAYS |
|
|
|
|
Butalbital-Aspirin-Caff w/ Codeine Cap 50-325-40-30 MG |
50-325-40-30 MG |
180 |
Capsules |
30 |
DAYS |
|
|
|
|
Butorphanol Tartrate Nasal Soln 10 MG/ML |
10 MG/ML |
3 |
Bottles |
30 |
DAYS |
|
|
|
|
Hydrocodone-Acetaminophen Soln 7.5-325 MG/15ML |
2.5-108 MG/5ML ; 5-217 MG/10ML ; 7.5-325 MG/15ML |
2700 |
mLs |
30 |
DAYS |
|
|
|
|
Hydrocodone-Acetaminophen Tab 10-300 MG |
10-300 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Hydrocodone-Acetaminophen Tab 10-325 MG |
10-325 MG |
180 |
|
30 |
DAYS |
|
|
|
|
Hydrocodone-Acetaminophen Tab 5-325 MG |
5-325 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
|
Hydrocodone-Acetaminophen Tab 7.5-300 MG |
7.5-300 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Hydrocodone-Acetaminophen Tab 7.5-325 MG |
7.5-325 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Hydrocodone-Ibuprofen Tab 7.5-200 MG |
7.5-200 MG |
150 |
Tablets |
30 |
DAYS |
|
|
|
|
Levorphanol Tartrate Tab 2 MG |
2 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Levorphanol Tartrate Tab 3 MG |
3 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Meperidine HCl Tab 50 MG |
50 MG |
360 |
Tablet |
30 |
DAYS |
|
|
|
|
Methadone HCl Tab 10 MG |
10 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Methadone HCl Tab 5 MG |
5 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Methadone HCl Tab For Oral Susp 40 MG |
40 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Oxycodone HCl Cap 5 MG |
5 MG |
360 |
Capsules |
30 |
DAYS |
|
|
|
|
Oxycodone HCl Conc 100 MG/5ML (20 MG/ML) |
10 MG/0.5ML ; 100 MG/5ML |
270 |
mLs |
30 |
DAYS |
|
|
|
|
Oxycodone HCl Soln 5 MG/5ML |
5 MG/5ML |
5400 |
mLs |
30 |
DAYS |
|
|
|
|
Oxycodone HCl Tab 10 MG |
10 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Oxycodone HCl Tab 20 MG |
20 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Oxymorphone HCl Tab 10 MG |
10 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Oxymorphone HCl Tab 5 MG |
5 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Pentazocine w/ Naloxone Tab 50-0.5 MG |
50-0.5 MG |
360 |
|
30 |
DAYS |
|
|
|
|
Tramadol HCl Tab 100 MG |
100 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Tramadol HCl Tab 50 MG |
50 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
|
Tramadol-Acetaminophen Tab 37.5-325 MG |
37.5-325 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Acetaminophen/caffeine/di ; Trezix |
Acetaminophen-Caffeine-Dihydrocodeine Cap 320.5-30-16 MG |
320.5-30-16 MG |
300 |
Capsules |
30 |
DAYS |
|
|
|
Acetaminophen/codeine |
Acetaminophen w/ Codeine Soln 120-12 MG/5ML |
120-12 MG/5ML ; 300-30 MG/12.5ML |
2700 |
mLs |
30 |
DAYS |
|
|
|
Apadaz ; Benzhydrocodone/acetamino |
Benzhydrocodone HCl-Acetaminophen Tab 4.08-325 MG |
4.08-325 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Apadaz ; Benzhydrocodone/acetamino |
Benzhydrocodone HCl-Acetaminophen Tab 6.12-325 MG |
6.12-325 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Apadaz ; Benzhydrocodone/acetamino |
Benzhydrocodone HCl-Acetaminophen Tab 8.16-325 MG |
8.16-325 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Codeine sulfate |
Codeine Sulfate Tab 15 MG |
15 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Codeine sulfate |
Codeine Sulfate Tab 30 MG |
30 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Codeine sulfate |
Codeine Sulfate Tab 60 MG |
60 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Dilaudid |
Hydromorphone HCl Liqd 1 MG/ML |
1 MG/ML |
1440 |
mLs |
30 |
DAYS |
|
|
|
Dilaudid |
Hydromorphone HCl Tab 2 MG |
2 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Dilaudid |
Hydromorphone HCl Tab 4 MG |
4 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Dilaudid |
Hydromorphone HCl Tab 8 MG |
8 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Fioricet/codeine |
Butalbital-Acetaminophen-Caff w/ COD Cap 50-300-40-30 MG |
50-300-40-30 MG |
180 |
Capsules |
30 |
DAYS |
|
|
|
Hydrocodone bitartrate/ac |
Hydrocodone-Acetaminophen Tab 2.5-325 MG |
2.5-325 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Hydrocodone/ibuprofen |
Hydrocodone-Ibuprofen Tab 10-200 MG |
10-200 MG |
150 |
Tablets |
30 |
DAYS |
|
|
|
Hydrocodone/ibuprofen |
Hydrocodone-Ibuprofen Tab 5-200 MG |
5-200 MG |
150 |
Tablets |
30 |
DAYS |
|
|
|
Lortab |
Hydrocodone-Acetaminophen Soln 10-300 MG/15ML |
10-300 MG/15ML |
2025 |
mLs |
30 |
DAYS |
|
|
|
Meperidine hcl |
Meperidine HCl Oral Soln 50 MG/5ML |
50 MG/5ML |
1800 |
mLs |
30 |
DAYS |
|
|
|
Methadone hcl |
Methadone HCl Soln 10 MG/5ML |
10 MG/5ML |
450 |
mLs |
30 |
DAYS |
|
|
|
Methadone hcl |
Methadone HCl Soln 5 MG/5ML |
5 MG/5ML |
900 |
mLs |
30 |
DAYS |
|
|
|
Methadose ; Methadose sugar-free |
Methadone HCl Conc 10 MG/ML |
10 MG/ML ; 5 MG/0.5ML |
90 |
mLs |
30 |
DAYS |
|
|
|
Morphine sulfate |
Morphine Sulfate Oral Soln 10 MG/5ML |
10 MG/5ML |
2700 |
mLs |
30 |
DAYS |
|
|
|
Morphine sulfate |
Morphine Sulfate Oral Soln 100 MG/5ML (20 MG/ML) |
100 MG/5ML ; 20 MG/ML |
270 |
mLs |
30 |
DAYS |
|
|
|
Morphine sulfate |
Morphine Sulfate Oral Soln 20 MG/5ML |
20 MG/5ML |
1350 |
mLs |
30 |
DAYS |
|
|
|
Morphine sulfate |
Morphine Sulfate Tab 15 MG |
15 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Morphine sulfate |
Morphine Sulfate Tab 30 MG |
30 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Nalocet ; Oxycodone/acetaminophen |
Oxycodone w/ Acetaminophen Tab 2.5-300 MG |
2.5-300 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Nucynta |
Tapentadol HCl Tab 100 MG |
100 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Nucynta |
Tapentadol HCl Tab 50 MG |
50 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Nucynta |
Tapentadol HCl Tab 75 MG |
75 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Oxaydo |
Oxycodone HCl Tab |
7.5 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Oxaydo |
Oxycodone HCl Tab 5 MG |
5 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Oxycodone and acetaminoph ; Prolate |
Oxycodone w/ Acetaminophen Tab 7.5-300 MG |
7.5-300 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Oxycodone hydrochloride ; Roxybond |
Oxycodone HCl Tab Abuse Deter |
5 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Oxycodone hydrochloride ; Roxybond |
oxycodone hcl tab abuse deter |
10 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Oxycodone hydrochloride ; Roxybond |
Oxycodone HCl Tab Abuse Deter |
15 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Oxycodone hydrochloride ; Roxybond |
Oxycodone HCl Tab Abuse Deter |
30 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Oxycodone hydrochloride/a |
Oxycodone w/ Acetaminophen Soln 5-325 MG/5ML |
5-325 MG/5ML |
1800 |
mLs |
30 |
DAYS |
|
|
|
Oxycodone hydrochloride/a ; Prolate |
Oxycodone w/ Acetaminophen Soln |
10-300 MG/5ML |
900 |
mLs |
30 |
DAYS |
|
|
|
Oxycodone/acetaminophen ; Prolate |
Oxycodone w/ Acetaminophen Tab 10-300 MG |
10-300 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Oxycodone/acetaminophen ; Prolate |
Oxycodone w/ Acetaminophen Tab 5-300 MG |
5-300 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Percocet |
Oxycodone w/ Acetaminophen Tab 10-325 MG |
10-325 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Percocet |
Oxycodone w/ Acetaminophen Tab 2.5-325 MG |
2.5-325 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Percocet |
Oxycodone w/ Acetaminophen Tab 5-325 MG |
5-325 MG |
360 |
Tablets |
30 |
DAYS |
|
|
|
Percocet |
Oxycodone w/ Acetaminophen Tab 7.5-325 MG |
7.5-325 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Qdolo ; Tramadol hydrochloride |
Tramadol HCl Oral Soln |
5 MG/ML |
2400 |
mLs |
30 |
DAYS |
|
|
|
Roxicodone |
Oxycodone HCl Tab 15 MG |
15 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Roxicodone |
Oxycodone HCl Tab 30 MG |
30 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Seglentis |
Celecoxib-Tramadol HCl Tab |
56-44 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Tramadol hydrochloride |
tramadol hcl tab |
25 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Tramadol hydrochloride |
tramadol hcl tab |
75 MG |
150 |
Tablets |
30 |
DAYS |
|
|
|
Xodol |
Hydrocodone-Acetaminophen Tab 5-300 MG |
5-300 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
Acetaminophen w/ Codeine Tab 300-15 MG |
300-15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Acetaminophen w/ Codeine Tab 300-30 MG |
300-30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Acetaminophen w/ Codeine Tab 300-60 MG |
300-60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Acetaminophen-Caffeine-Dihydrocodeine Tab 325-30-16 MG |
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30 MG |
50-325-40-30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Butalbital-Aspirin-Caff w/ Codeine Cap 50-325-40-30 MG |
50-325-40-30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Butorphanol Tartrate Nasal Soln 10 MG/ML |
10 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Hydrocodone-Acetaminophen Soln 7.5-325 MG/15ML |
2.5-108 MG/5ML ; 5-217 MG/10ML ; 7.5-325 MG/15ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Hydrocodone-Acetaminophen Tab 10-300 MG |
10-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Hydrocodone-Acetaminophen Tab 10-325 MG |
10-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Hydrocodone-Acetaminophen Tab 5-325 MG |
5-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Hydrocodone-Acetaminophen Tab 7.5-300 MG |
7.5-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Hydrocodone-Acetaminophen Tab 7.5-325 MG |
7.5-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Hydrocodone-Ibuprofen Tab 7.5-200 MG |
7.5-200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Levorphanol Tartrate Tab 2 MG |
2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Levorphanol Tartrate Tab 3 MG |
3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Meperidine HCl Tab 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Methadone HCl Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Methadone HCl Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Methadone HCl Tab For Oral Susp 40 MG |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Oxycodone HCl Cap 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Oxycodone HCl Conc 100 MG/5ML (20 MG/ML) |
10 MG/0.5ML ; 100 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Oxycodone HCl Soln 5 MG/5ML |
5 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Oxycodone HCl Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Oxycodone HCl Tab 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Oxymorphone HCl Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Oxymorphone HCl Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Pentazocine w/ Naloxone Tab 50-0.5 MG |
50-0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Tramadol HCl Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Tramadol HCl Tab 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Tramadol-Acetaminophen Tab 37.5-325 MG |
37.5-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Acetaminophen/caffeine/di ; Trezix |
Acetaminophen-Caffeine-Dihydrocodeine Cap 320.5-30-16 MG |
320.5-30-16 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Acetaminophen/codeine |
Acetaminophen w/ Codeine Soln 120-12 MG/5ML |
120-12 MG/5ML ; 300-30 MG/12.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Apadaz ; Benzhydrocodone/acetamino |
Benzhydrocodone HCl-Acetaminophen Tab 4.08-325 MG |
4.08-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Apadaz ; Benzhydrocodone/acetamino |
Benzhydrocodone HCl-Acetaminophen Tab 6.12-325 MG |
6.12-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Apadaz ; Benzhydrocodone/acetamino |
Benzhydrocodone HCl-Acetaminophen Tab 8.16-325 MG |
8.16-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Codeine sulfate |
Codeine Sulfate Tab 15 MG |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Codeine sulfate |
Codeine Sulfate Tab 30 MG |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Codeine sulfate |
Codeine Sulfate Tab 60 MG |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Dilaudid |
Hydromorphone HCl Liqd 1 MG/ML |
1 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Dilaudid |
Hydromorphone HCl Tab 2 MG |
2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Dilaudid |
Hydromorphone HCl Tab 4 MG |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Dilaudid |
Hydromorphone HCl Tab 8 MG |
8 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fioricet/codeine |
Butalbital-Acetaminophen-Caff w/ COD Cap 50-300-40-30 MG |
50-300-40-30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Hydrocodone bitartrate/ac |
Hydrocodone-Acetaminophen Tab 2.5-325 MG |
2.5-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Hydrocodone/ibuprofen |
Hydrocodone-Ibuprofen Tab 10-200 MG |
10-200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Hydrocodone/ibuprofen |
Hydrocodone-Ibuprofen Tab 5-200 MG |
5-200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lortab |
Hydrocodone-Acetaminophen Soln 10-300 MG/15ML |
10-300 MG/15ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Meperidine hcl |
Meperidine HCl Oral Soln 50 MG/5ML |
50 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Methadone hcl |
Methadone HCl Soln 10 MG/5ML |
10 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Methadone hcl |
Methadone HCl Soln 5 MG/5ML |
5 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Methadose ; Methadose sugar-free |
Methadone HCl Conc 10 MG/ML |
10 MG/ML ; 5 MG/0.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Morphine sulfate |
Morphine Sulfate Oral Soln 10 MG/5ML |
10 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Morphine sulfate |
Morphine Sulfate Oral Soln 100 MG/5ML (20 MG/ML) |
100 MG/5ML ; 20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Morphine sulfate |
Morphine Sulfate Oral Soln 20 MG/5ML |
20 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Morphine sulfate |
Morphine Sulfate Tab 15 MG |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Morphine sulfate |
Morphine Sulfate Tab 30 MG |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nalocet ; Oxycodone/acetaminophen |
Oxycodone w/ Acetaminophen Tab 2.5-300 MG |
2.5-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nucynta |
Tapentadol HCl Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nucynta |
Tapentadol HCl Tab 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nucynta |
Tapentadol HCl Tab 75 MG |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxaydo |
Oxycodone HCl Tab |
7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxaydo |
Oxycodone HCl Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxycodone and acetaminoph ; Prolate |
Oxycodone w/ Acetaminophen Tab 7.5-300 MG |
7.5-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxycodone hydrochloride ; Roxybond |
Oxycodone HCl Tab Abuse Deter |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxycodone hydrochloride ; Roxybond |
Oxycodone HCl Tab Abuse Deter |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxycodone hydrochloride ; Roxybond |
Oxycodone HCl Tab Abuse Deter |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxycodone hydrochloride ; Roxybond |
oxycodone hcl tab abuse deter |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxycodone hydrochloride/a |
Oxycodone w/ Acetaminophen Soln 5-325 MG/5ML |
5-325 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxycodone hydrochloride/a ; Prolate |
Oxycodone w/ Acetaminophen Soln |
10-300 MG/5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxycodone/acetaminophen ; Prolate |
Oxycodone w/ Acetaminophen Tab 10-300 MG |
10-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Oxycodone/acetaminophen ; Prolate |
Oxycodone w/ Acetaminophen Tab 5-300 MG |
5-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Percocet |
Oxycodone w/ Acetaminophen Tab 10-325 MG |
10-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Percocet |
Oxycodone w/ Acetaminophen Tab 2.5-325 MG |
2.5-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Percocet |
Oxycodone w/ Acetaminophen Tab 5-325 MG |
5-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Percocet |
Oxycodone w/ Acetaminophen Tab 7.5-325 MG |
7.5-325 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Qdolo ; Tramadol hydrochloride |
Tramadol HCl Oral Soln |
5 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Roxicodone |
Oxycodone HCl Tab 15 MG |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Roxicodone |
Oxycodone HCl Tab 30 MG |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Seglentis |
Celecoxib-Tramadol HCl Tab |
56-44 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tramadol hydrochloride |
tramadol hcl tab |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tramadol hydrochloride |
tramadol hcl tab |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xodol |
Hydrocodone-Acetaminophen Tab 5-300 MG |
5-300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
||||||||||||||||||||||||||
|
Program Maximum Daily Doses
Quantities of Single Ingredient Opioid IR Agent(s) above the program quantity limit but less than or equal to the Program Maximum Daily Dose (maximum mg allowed with highest dosage strength) or for patients under the age of 18 years (products containing tramadol, dihydrocodeine, and codeine any quantities) will be approved when ALL of the following are met:
Length of Approval: 1 month for dose titration requests and up to 6 months for all other requests
Quantities of Single Ingredient Opioids IR Agent(s) which exceed the Program Maximum Daily Dose (maximum mg allowed with highest dosage strength) or for patients under the age of 18 years (products containing tramadol, dihydrocodeine, and codeine any quantities) will be approved when ALL of the following are met:
Length of Approval: 1 month for dose titration requests and up to 6 months for all other requests
Quantities of Combination Ingredient Opioids IR Agent(s) which exceed the Daily Quantity Limit or for patients under the age of 18 years (products containing tramadol, dihydrocodeine, and codeine any quantities) will be approved when ALL of the following are met:
Length of Approval: 1 month for dose titration requests and up to 6 months for all other requests |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
ALBP _ Commercial _ CS _ Opioids_IR_QL _ProgSum_ 04-01-2025 _© Copyright Prime Therapeutics LLC. January 2025 All Rights Reserved