This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.

This is an optional program for self-funded groups.

FDA APPROVED INDICATIONS AND DOSAGE^4-41

Single Ingredient Agent(s)	Indication(s)	Dosage
butorphanola Nasal spray	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	The usual recommended initial dose is 1 mg (1 spray in one nostril).  If adequate pain relief is not achieved within 60 to 90 minutes, an additional 1 mg dose may be given. The initial dose sequence outlined above may be repeated in 3 to 4 hours as required after the second dose of the sequence. Depending on the severity of the pain, an initial dose of 2 mg (1 spray in each nostril) may be used in patients who will be able to remain recumbent in the event drowsiness or dizziness occurs. In such patients, single additional 2 mg doses should not be given for 3 to 4 hours.
codeinea Tablet	Management of mild to moderate pain, where treatment with an opioid is appropriate and for which alternative treatments are inadequate.	15 mg to 60 mg every four hours as needed for pain. The maximum 24-hour dose is 360 mg.
Dilaudid (hydromorphone)a Tablet Liquid	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Oral solution: Initial dose of 2.5 mg to 10 mg every 3 to 6 hours as needed. Tablets: Initial dose of 2 mg to 4 mg every 4 to 6 hours.
Levorphanola Tablet	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Initial dose 1 mg to 2 mg every  6 to 8 hours as needed. If necessary, the dose may be increased up to 3 mg every 6 to 8 hours.
Meperidinea Tablet Solution	Management of acute pain, severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Adults: 50 mg to 150 mg every 3 to 4 hours as needed. Pediatric: 1.1 mg/kg to 1.8 mg/kg every 3 to 4 hours as needed. If adequate pain management cannot be achieved with a total daily dose of 600 mg or less, discontinue meperidine by tapering dose and selecting an alternative treatment
Methadose,Methadonea Tablet Soluble tablet Solution Concentrate	Management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.	Initial dose of 2.5 mg every 8 to 12 hours.
Morphine sulfatea Tablet Concentrate Solution	Management of acute and chronic pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Tablets: 15 mg to 30 mg every 4 hours as needed Oral Solution: 10 mg to 20 mg every 4 hours as needed
Oxaydo, Roxybond, Roxicodone (oxycodone)a Capsule Tablet Solution Concentrate	Management of acute and chronic pain in adults severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Initial dose of 5 mg to 15 mg every 4 to 6 hours.
oxymorphonea Tablet	Management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	10 mg to 20 mg every 4 to 6 hours
Nucynta (tapentadol) Tablet	Management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	50 mg to 100 mg every 4 to 6 hours. Daily doses greater than 700 mg on the first day of therapy and 600 mg on subsequent days have not been studied and are not recommended.
Qdolo (tramadol) Oral solution	Management of pain in adults that is severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Initial dose: 25 mg/day and titrate in 25 mg increments as separate doses every 3 days to reach 100 mg/day (25 mg four times daily). After titration, may administer 50 mg to 100 mg every 4 to 6 hours. Max of 400 mg per day.
Ultrama, Tramadol Tablet	Management of pain in adults that is severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	50 mg to 100 mg every 4 to 6 hours as needed. Max dose of 400 mg per day.

a – generic available

Combination Ingredient Agent(s)	Indication(s)	Dosage
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.	1-2 tablets every 4 to 6 hours. Dosage should not exceed 12 tablets in a 24 hour period.
Tylenol w/Codeine (acetaminophen/ codeine)a Tablet Oral solution	Management of mild to moderate pain, where treatment with an opioid is appropriate and for which alternative treatments are inadequate.	Tablets: Based on codeine component 15 mg and 30 mg: one to two every 4 hours. 60 mg: one every 4 hours. Max of 360 mg of codeine per day. Oral solution: 15 mL every 4 hours.
Fioricet w/Codeine   (butalbital/ acetaminophen/ caffeine/codeine)a Capsule	Management of the symptom complex of tension (or muscle contraction) headache when non-opioid analgesic and alternative treatments are inadequate.	One or two capsules every 4 hours. Total daily dosage should not exceed 6 capsules.
butalbital/aspirin/ caffeine/codeinea Capsule	Management of the symptom complex of tension (or muscle contraction) headache when non-opioid analgesic and alternative treatments are inadequate.	One or two capsules every 4 hours as needed. Total daily dosage should not exceed 6 capsules.
Trezix, Acetaminophen/ caffeine/ dihydrocodeine Capsule Tablet	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Two capsules/tablets every four hours, as needed.  No more than five doses, or ten capsules/tablets should be taken in a 24-hour period.
Hydrocodone/ Acetaminophena Solution	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	15 mL every 4 to 6 hours. Maximum 90 mLs per day.
Lortab (hydrocodone/ acetaminophen) Solution	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	11.25 mL every 4 to 6  hours. Maximum 67.5 mL per day.
hydrocodone/ acetaminophena Tablet	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Initial dose depends on hydrocodone dose: 5 mg: one to two tablets every 4 to 6 hours. Max of 8 tablets per day. 7.5 mg and 10 mg: one tablet every 4 to 6 hours. Max of 6 tablets per day.
Hydrocodone/ Ibuprofena Tablet	Short-term management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	One tablet every 4 to 6 hours, as needed. Dosage should not exceed 5 tablets in a 24-hour period.
Nalocet, Oxycodone/ Acetaminophen, Prolate Tablet Solution	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Tablet: One tablet every 6 hours as needed. Maximum dose based on oxycodone strength: 2.5 mg and 5 mg: 12 tablets daily. 7.5 mg: 8 tablets daily. 10 mg: 6 tablets daily. Oral solution: 5 mL every 6 hours as needed. Maximum dose based on oxycodone strength: 10 mg/300 mg: Max of 30 mL daily 5 mg/325 mg: Max of 60 mL daily
Percocet (oxycodone/ acetaminophen)a Tablet	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	One tablet every 6 hours as needed. Maximum dose based on oxycodone strength: 2.5 mg and 5 mg: 12 tablets daily. 7.5 mg: 8 tablets daily. 10 mg: 6 tablets daily.
oxycodone/ aspirina Tablet	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	One tablet every 6 hours as needed for pain. The maximum daily dose of aspirin should not exceed 4 grams or 12 tablets.
pentazocine/ naloxonea Tablet	Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	One or two tablets every 3 to 4 hours. Total daily dosage should not exceed 12 tablets.
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	Two tablets every 12 hours as needed for pain. Do not exceed recommended dose of Seglentis.
Ultracet (tramadol/ acetaminophen)a Tablet	Management of acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.	Two tablets every 4 to 6 hours as needed for pain relief, up to a maximum of 8 tablets per day for up to 5 days.

a – generic available

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. Three days or less will often be sufficient; more than seven days will rarely be needed.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 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, continuous 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) 2017 Guideline for Responsible, Safe, and Effective 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. Long-acting agents should only be used in the management of severe, intractable pain. The guidelines recommend the following for the treatment of chronic non-cancer pain:²

• Initiating therapy with an opioid:
  • Complete a comprehensive assessment and document comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history
  • Screen for opioid abuse, utilize prescription drug monitoring programs (PDMPs), and utilize urine drug testing (UDT) to identify opioid abusers, reduce opioid abuse, and potentially reduce doctor shopping. Utilize at initiation of therapy and to monitor adherence
  • Establish appropriate physical and psychological diagnoses prior to initiating therapy
  • A pain management consultation, for non-pain physicians, if use of chronic opioids is planned or in patients where the total daily dose will exceed the recommended CDC morphine equivalent therapy
  • Establish medical necessity prior to initiation or maintenance of opioid therapy based on average, moderate, or severe (≥4 on a scale of 0-10) pain and/or disability
  • Establish treatment goals of opioid therapy with regard to pain relief and improvement in function
  • Obtain a robust agreement prior to initiating and maintaining opioid therapy. Agreements reduce over-use, misuse, abuse, and diversion
• Assessing improvement:
  • Assess improvement based on analgesia, activity, aberrant behavior, and adverse effects. Clinicians should document at least a 30% improvement in pain or disability without adverse consequences
  • Therapy must be started with short-acting opioids and should be maintained with lowest effective doses
  • Evidence of effectiveness is similar for long-acting and short-acting opioids with increased prevalence of adverse consequences of long-acting opioids
  • Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting opioids or moderate doses of long-acting opioids
  • Low dose should be considered up to 40 MME, 41-90 MME should be considered moderate dose, and greater than 91 MME as high dose
  • Long-acting opioids should not be utilized for initial opioid therapy
  • Monitor adherence via UDT and PDMP to identify patients who are non-compliant or abusing prescription or illicit drugs
  • Chronic opioid therapy may be continued, with continuous adherence monitoring, and modified in conjunction with or after failure of other modalities of treatments.

The 2016 CDC guidelines for Prescribing Opioids for Chronic Pain recommend the following:¹

• When to initiate or continue opioids for chronic pain:
  • Clinicians should consider opioids only if expected benefits for both pain and function are anticipated to outweigh risks to the patients. Opioids should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate
  • Clinicians should establish treatment goals with all patients prior to starting opioid therapy for chronic pain. Goals should include realistic goals for pain and function, and how to discontinue therapy if benefits do not outweigh the risks. Clinicians should only continue therapy with opioids if there is clinically meaningful improvement in pain and function that outweigh the risks to patient safety
  • Clinicians should discuss the risks and realistic benefits of opioid therapy prior to starting and periodically during therapy
• Opioid selection, dosage, duration, follow-up, and discontinuation:
  • Clinicians should prescribe immediate release opioids instead of extended release/long acting opioids when starting opioid therapy for chronic pain
  • The lowest effective dose should be prescribed when opioids are started. Clinicians should use caution when prescribing opioids, should reassess evidence of benefits and risks when increasing doses to greater than or equal to 50 morphine milligram equivalents (MME)/day, and should avoid increasing doses to greater than or equal to 90 MME/day or carefully justify titrating to doses greater than or equal to 90 MME/day
  • Opioids for acute pain should be prescribed at the lowest effective dose of immediate release opioids and should be prescribed at a quantity no greater than necessary for the expected duration of pain. Three days or less will often be sufficient; more than seven days will rarely be needed
  • Benefits and risks should be evaluated within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalations. Benefits and risks of continued therapy should be evaluated every 3 months or more frequently
• Assessing Risk and addressing Harms of Opioid use:
  • Clinicians should incorporate into the management plan strategies to mitigate risk, including offering naloxone when there is increased risk of opioid overdose, such as history of overdose, history of substance abuse disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use
  • Patient’s history of controlled substance use should be reviewed by the clinician using state prescription drug monitoring program (PDMP) data to determine if the patient is receiving opioid dosages or dangerous combinations that put the patient at high risk for overdose. PDMP data should be reviewed when starting opioid therapy for chronic pain and periodically during opioid therapy, ranging from every prescription to every 3 months
  • Clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription and illicit drugs
  • Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible

The CDC guideline for opioid prescribing 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

1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. ePub: 15 March 2016. DOI: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
2. Manchikanti L, Kaye AM, Knezevic NN, et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician 2017;20:S3-S92.
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. April 2017.
4. butorphanol tartrate nasal solution prescribing information. Apotex Corp. January 2021.
5. codeine prescribing information. Hikma Pharmaceuticals USA Inc. March 2021.
6. meperidine prescribing information. West-Ward Pharmaceuticals Corp. August 2022.
7. Dilaudid prescribing information. Purdue Pharma LP. March 2021.
8. levorphanol prescribing information. Lannett Company, Inc. December 2021.
9. methadone prescribing information. VistaPharm, Inc. January 2022.
10. Methadose prescribing information. SpecGX, LLC. May 2022.
11. morphine prescribing information. Hikma Pharmaceuticals USA Inc. April 2022.
12. oxycodone prescribing information. ANI Pharmaceuticals Inc. August 2021.
13. oxymorphone prescribing information. West-Ward Pharmaceuticals Corp. August 2020.
14. Oxaydo prescribing information. Zyla Life Sciences US Inc. March 2021.
15. Nucynta prescribing information. Collegium Pharm, Inc. March 2021.
16. Ultram prescribing information Janssen Pharms. September 2021.
17. Roxicodone prescribing information. Specgx LLC. March 2021.
18. hydrocodone/ibuprofen prescribing information. Amneal Pharmaceuticals, LLC. October 2021.
19. Ultracet prescribing information. Jassen Pharma. September 2021.
20. Oxycodone/aspirin prescribing information. Actavis Labs FL Inc. October 2019.
21. Apadaz prescribing information. KVK Tech Inc. March 2021.
22. Percocet prescribing information. Endo Pharmaceuticals Inc. July 2020.
23. Oxycodone/acetaminophen 300 mg prescribing information. FH2 Pharma LLC. June 2021.
24. Prolate prescribing information. Forte Bio-Pharma LLC. September 2021.
25. Tylenol with codeine prescribing information. Janssen Pharms. October 2019.
26. Lortab prescribing information. Akorn, Inc. May 2021.
27. Hydrocodone/Acetaminophen tablet prescribing information. Amneal Pharmaceuticals, LLC. September 2021.
28. Hydrocodone/Acetaminophen oral solution prescribing information. Eywa Pharma Inc. April 2021.
29. Hydrocodone/Acetaminophen 300 mg prescribing information. SpecGx LLC. March 2021.
30. Trezix prescribing information. Wraser Pharms LLC. July 2017.
31. Butalbital, Aspirin, Caffeine, Codeine prescribing information. Activis Pharma, Inc. April 2021.
32. Fioricet with Codeine prescribing information. Actavis Pharma, Inc. March 2021.
33. Pentazocine/naloxone prescribing information. Actavis Pharma, Inc. July 2020.
34. Acetaminophen/codeine solution prescribing information. Akorn. May 2022.
35. Qdolo prescribing information. Athena Bioscience, LLC. September 2021.
36. Acetaminophen/caffeine/dihydrocodeine prescribing information. Xspire Pharma, LLC. January 2021.
37. Seglentis prescribing information. Kowa Pharmaceuticals America, Inc. October 2021.
38. Oxycodone/acetaminophen 5/325 solution prescribing information. Nostrum Laboratories, Inc. September 2021.
39. Roxybond prescribing information. Protega Pharms. March 2021.

Opioids IR Duration Limit and Quantity Limit

OBJECTIVE

The intent of the program is to help direct appropriate use of immediate release opioids based on CDC guideline recommendation on the duration of acute opioid use. According to CDC, 3 days or less will often be sufficient; more than 7 days will rarely be needed. Opioid naïve patients will be limited to a 7 day initial opioid IR duration limit. The program will also allow continuation of the requested agent when there is information that the patient is not opioid naïve. Requests for therapy longer than 7 days for patients who do not have opioid use in the past 180 days will result in an alert to patients to seek prior authorization for extended therapy. 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. The program will also evaluate total MED. If the total MED for the patient is at or over 210 mg, the prescriber must acknowledge the risks associated with the prescribed MED and provide a treatment plan to reduce the MED or provide rationale why the MED cannot be reduced. For targets of the quantity limit, a maximum daily dose and age limit applies.

TARGET AGENT(S) FOR DURATION AND QUANTITY LIMIT(S)

Brand (generic)	GPI	Daily Quantity Limit	Maximum Duration of 1st Fillb	Age Limit
SINGLE INGREDIENT AGENT(S)
butorphanola
10 mg/mL nasal spray	65200020102050	0.25 mL	7 days	NA
Codeine
15 mg tablet	65100020200305	6 tablets	7 days	≥18 years
30 mg tableta	65100020200310	6 tablets	7 days	≥18 years
60 mg tablet	65100020200315	6 tablets	7 days	≥18 years
Dilaudid (hydromorphone)a
2 mg tablet	65100035100310	6 tablets	7 days	NA
4 mg tablet	65100035100320	6 tablets	7 days	NA
8 mg tablet	65100035100330	6 tablets	7 days	NA
1 mg/mL liquid	65100035100920	48 mL	7 days	NA
Levorphanola
2 mg tablet	65100040100305	4 tablets	7 days	NA
3 mg tablet	65100040100310	4 tablets	7 days	NA
Meperidine
50 mg tablet	65100045100305	12 tablets	7 days	NA
50 mg/5 mL solution	65100045102060	60 mL	7 days	NA
methadonea
5 mg tablet	65100050100305	3 tablets	7 days	NA
10 mg tablet	65100050100310	3 tablets	7 days	NA
Methadose, Methadonea
40 mg soluble tablet	65100050107320	3 tablets	7 days	NA
5 mg/5 mL solution	65100050102010	30 mL	7 days	NA
10 mg/5 mL solution	65100050102015	15 mL	7 days	NA
10 mg/mL concentrate	65100050101310	3 mL	7 days	NA
Morphine sulfatea
15 mg tablet	65100055100310	12 tablets	7 days	NA
30 mg tablet	65100055100315	6 tablets	7 days	NA
10 mg/5 mL solution	65100055102065	90 mL	7 days	NA
20 mg/5 mL solution	65100055102070	45 mL	7 days	NA
20 mg/mL concentrate	65100055102090	9 mL	7 days	NA
Oxaydo, Roxybond, Roxicodone (oxycodone)
5 mg capsulea	65100075100110	12 capsules	7 days	NA
5 mg tableta	65100075100310	12 tablets	7 days	NA
5 mg tablet	6510007510A530	12 tablets	7 days	NA
7.5 mg tablet	65100075100315	6 tablets	7 days	NA
10 mg tableta	65100075100320	6 tablets	7 days	NA
15 mg tableta	65100075100325	6 tablets	7 days	NA
15 mg tablet	6510007510A540	6 tablets	7 days	NA
20 mg tableta	65100075100330	6 tablets	7 days	NA
30 mg tableta	65100075100340	6 tablets	7 days	NA
30 mg tablet	6510007510A560	6 tablets	7 days	NA
5 mg/5 mL solutiona	65100075102005	180 mL	7 days	NA
20 mg/mL concentratea	65100075101320	9 mL	7 days	NA
oxymorphonea
5 mg tablet	65100080100305	6 tablets	7 days	NA
10 mg tablet	65100080100310	6 tablets	7 days	NA
Nucynta (tapentadol)
50 mg tablet	65100091100320	6 tablets	7 days	NA
75 mg tablet	65100091100330	6 tablets	7 days	NA
100 mg tablet	65100091100340	6 tablets	7 days	NA
Qdolo, Ultram, Tramadol
50 mg tableta	65100095100320	8 tablets	7 days	≥18 years
100 mg tableta	65100095100340	4 tablets	7 days	≥18 years
5 mg/mL solution	65100095102005	80 mL	7 days	≥18 years
COMBINATION INGREDIENT AGENT(S)
Apadaz, Benzhydrocodone/acetaminophen
4.08/325 mg tablet	65990002020310	12 tablets	7 days	NA
6.12/325 mg tablet	65990002020320	12 tablets	7 days	NA
8.16/325 mg tablet	65990002020330	12 tablets	7 days	NA
Tylenol w/Codeine (acetaminophen/codeine)a
120 mg/12 mg/5 mL solution	65991002052020	90 mL	7 days	≥18 years
300 mg/15 mg tablet	65991002050310	12 tablets	7 days	≥18 years
300 mg/30 mg tablet	65991002050315	12 tablets	7 days	≥18 years
300 mg/60 mg tablet	65991002050320	6 tablets	7 days	≥18 years
Fioricet w/Codeine (butalbital/acetaminophen/caffeine/codeine)a
50 mg/300 mg/40 mg/30 mg capsule	65991004100113	6 capsules	7 days	≥18 years
50 mg/325 mg/40 mg/30 mg capsule	65991004100115	6 capsules	7 days	≥18 years
butalbital/aspirin/caffeine/codeinea
50 mg/325 mg/40 mg/30 mg capsule	65991004300115	6 capsules	7 days	≥18 years
Trezix, Acetaminophen/caffeine/dihydrocodeine
320.5 mg/30 mg/16 mg capsule	65991303050115	10 capsules	7 days	≥18 years
325 mg/30 mg/16 mg tablet	65991303050320	10 tablets	7 days	≥18 years
Lortab, Hydrocodone/acetaminophen
5 mg/300 mg tableta	65991702100309	8 tablets	7 days	NA
5 mg/325 mg tableta	65991702100356	8 tablets	7 days	NA
7.5 mg/300 mg tableta	65991702100322	6 tablets	7 days	NA
7.5 mg/325 mg tableta	65991702100358	6 tablets	7 days	NA
10 mg/300 mg tableta	65991702100375	6 tablets	7 days	NA
10 mg/325 mg tableta	65991702100305	6 tablets	7 days	NA
7.5 mg/325 mg/15 mL solutiona	65991702102015	90 mL	7 days	NA
10 mg/300 mg/15 mL solution	65991702102024	67.5 mL	7 days	NA
10 mg/325 mg/15 mL solution	65991702102025	90 mL	7 days	NA
Hydrocodone/Ibuprofen
5 mg/200 mg tablet	65991702500315	5 tablets	7 days	NA
7.5 mg/200 mg tableta	65991702500320	5 tablets	7 days	NA
10 mg/200 mg tablet	65991702500330	5 tablets	7 days	NA
Percocet, Prolate, Oxycodone/acetaminophen, Nalocet
2.5 mg/300 mg tablet	65990002200303	12 tablets	7 days	NA
2.5 mg/325 mg tableta	65990002200305	12 tablets	7 days	NA
5 mg/300 mg tablet	65990002200308	12 tablets	7 days	NA
5 mg/325 mg tableta	65990002200310	12 tablets	7 days	NA
7.5 mg/300 mg tablet	65990002200325	8 tablets	7 days	NA
7.5 mg/325 mg tableta	65990002200327	8 tablets	7 days	NA
10 mg/300 mg tablet	65990002200333	6 tablets	7 days	NA
10 mg/325 mg tableta	65990002200335	6 tablets	7 days	NA
5 mg/325 mg/5 mL solution	65990002202005	60 mL	7 days	NA
10 mg/300 mg/5 mL solution	65990002202020	30 mL	7 days	NA
Oxycodone/Aspirin
4.8355 mg/325 mg tablet	65990002220340	12 tablets	7 days	NA
pentazocine/naloxonea
50 mg/0.5 mg tablet	65200040300310	12 tablets	7 days	NA
Seglentis (celecoxib/tramadol)
56 mg/44 mg tablet	65995002100320	4 tablets	7 days	≥18 years
Ultracet (tramadol/acetaminophen)a
37.5 mg/325 mg tablet	65995002200320	8 tablets	7 days	≥18 years

a – generic available

b – 1st fill defined as a fill with no previous fills in the past 60 days

PRIOR AUTHORIZATION CRITERIA FOR APPROVAL

TARGET DURATION AND QUANTITY LIMIT AGENT(S) will be approved for exceeding the 7-day supply limit, exceeding the daily quantity limit, or for patients under the age of 18 years (products containing tramadol, dihydrocodeine, and codeine any quantities) when ALL of the following are met:

1. ONE of the following:
   1. Information has been provided that the patient is currently using opioid(s)

OR

1. 2. The prescriber states the patient is NOT new to opioid therapy AND is at risk if therapy is changed

OR

1. 3. The patient has a diagnosis of chronic cancer pain due to an active malignancy

OR

1. 4. The patient is eligible for hospice OR palliative care

OR

1. 5. The patient is undergoing treatment of chronic non-cancer pain and ALL of the following:
      1. The prescriber has provided information in support of use of immediate-release single or combination opioids for an extended duration (>7 days)

AND

1. 1. 2. A formal, consultative evaluation which includes BOTH of the following has been conducted:
         1. Diagnosis

AND

1. 1. 1. 2. A complete medical history which includes previous and current pharmacological and non-pharmacological therapy

AND

1. 1. 3. A patient-specific pain management plan is on file for the patient

AND

1. 1. 4. The patient is not diverting controlled substances, according to the patient’s records in the state’s prescription drug monitoring program (PDMP), if applicable

AND

2. ONE of the following:
   1. The patient is not currently using buprenorphine or buprenorphine/naloxone for opioid dependence treatment

OR

1. 2. The prescriber has provided information in support of use of concurrent use of opioids with buprenorphine or buprenorphine/naloxone for opioid dependence treatment due to one of the following:
      1. Dental procedure with dates
      2. Surgery with dates
      3. Acute injury with dates

AND

3. If the requested agent contains acetaminophen, then the requested dose of acetaminophen does NOT exceed 4 grams per day

AND

4. If the requested agent contains tramadol, dihydrocodeine, OR codeine, then ONE of the following:
   1. The patient is 12 to less than 18 years of age AND the requested agent will NOT be used for post-operative pain management following a tonsillectomy and/or adenoidectomy

OR

1. 2. The patient is 18 years of age or over

AND

5. If the patient’s total morphine equivalent dose (MED) exceeds 210 mg per day, then BOTH of the following:
   1. The prescriber acknowledges that the patient is using opioids (total daily dose of all opioids) that are at or over 210 mg MED and the associated risks

      AND

1. 2. ONE of the following:
      1. The prescriber has provided a treatment plan to reduce the MED to less than 210 mg

      OR

1. 1. 2. The prescriber has provided rationale as to why the patient cannot tolerate a reduction in MED

AND

6. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program daily quantity limit

OR

1. 2. ALL of the following:
      1. The requested quantity (dose) is greater than the program daily quantity limit

AND

1. 1. 2. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose

AND

1. 1. 3. The requested quantity (dose)cannot be achieved with a lower quantity of a higher strength that does not exceed the program daily quantity limit

OR

1. 3. ALL of the following:
      1. The requested quantity (dose) is greater than the program daily quantity limit

AND

1. 1. 2. ONE of the following:
         1. The requested agent does not have a maximum FDA labeled  dose

OR

1. 1. 1. 2. The requested quantity (dose) is greater than the maximum FDA labeled dose

AND

1. 1. 3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 6 months

Grace Fill Allowance: Allow 1 grace fill providing up to 7 days of therapy

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.

 

 

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