CHIP opioid drug list and quantity limits
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This policy lists opioid analgesic drugs and establishes CHIP-specific quantity limits (adult and child) for each formulation that plans may use to authorize pharmacy claims; it applies to Capital BlueCross CHIP members in Pennsylvania (NC not listed).
No material clinical or coverage changes in this revision.
Coverage Criteria
Quantity limits list
Drugs listed are subject to the specified quantity limits for CHIP members; coverage depends on the member's contract.
No additional clinical criteria provided in the document; presence of the drug on this list does not guarantee it is a covered benefit under the member's contract.
Listing a drug or quantity limit in this policy does not guarantee that the drug is a covered benefit for a particular member. Coverage and benefit determinations are governed by the member's individual or group contract language. Providers and members must consult the member's benefit information or contact Capital BlueCross to confirm whether a listed drug is covered and to determine any applicable benefit limits before assuming authorization or submitting claims.
Coding and Measurement Windows
Provider Actions & Authorization Notes
Quantity limits enforced
Quantity limits are enforced. Adult and child windows must be applied as specified: adult = 5-day window, child = 3-day window. Specific per-drug/formulation limits from the policy source include (examples): APAPICODEINE SOL 120-12/5 — Adult Quantity Limit (5-day) = 450 mL/30 days; Child Quantity Limit (3-day) = 270 mL/30 days. APAPICODEINE SOL 300-30mg — Adult Quantity Limit (5-day) = 450 mL/30 days; Child Quantity Limit (3-day) = 270 mL/30 days. APAPICODEINE tablets 300-30mg — Adult Quantity Limit (5-day) = 30 tablets/30 days; Child Quantity Limit (3-day) = 18 tablets/30 days. APAPICODEINE tablets 300-60mg — Adult Quantity Limit (5-day) = 25 tablets/30 days; Child Quantity Limit (3-day) = 15 tablets/30 days. Buprenorphine transdermal systems (various mcg/hr strengths) — Adult Quantity Limit (5-day) = 4 systems/28 days; Child Quantity Limit (3-day) = NA. Apply these quantity windows and per-product limits when adjudicating claims or processing prior authorizations.
Benefit information
Providers and members should consult the member's benefit documents or contact Capital BlueCross to confirm coverage, benefit limits, and whether the service or medication is a covered benefit under the member's contract. The presence of a drug or rule in this policy does not guarantee coverage — benefit determinations must be made based on the applicable contract language.
Background
This document is an administrative update to the CHIP opioid drug list that specifies quantity limits for opioid analgesic formulations. The policy presents adult quantity limits measured on a 5‑day standard (reported per 30 days) and pediatric quantity limits measured on a 3‑day standard (reported per 30 days), and enumerates specific limits for individual formulations (examples include apap/codeine solutions and tablets, hydrocodone/APAP solutions and tablets, endocet, fentanyl lozenges, hydromorphone, methadone, morphine sulfate, NUCYNTA, oxycodone formulations, and tramadol products). This guidance is administrative only and does not replace clinical judgment; whether a listed product is payable depends on the member's contract and benefit design.
Definitions & Naming Conventions
Drug-Specific Quantity Limits
Revision History
Chip Opioid drug list update became effective; establishes CHIP quantity limits and adult/child windows for listed opioid formulations.
Policy clarifies that existence of the pharmacy policy does not guarantee coverage and directs members/providers to consult contract language or contact Capital BlueCross for benefit information.
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