CurrentCapital BluecrossPolicy N/A

Advantage - Opioid drug list update

This document lists opioid medications with formulary quantity limits and age-specific (adult/child) limits for Capital Bluecross Advantage effective January 1, 2025. It is intended for pharmacy benefit determination and applies to prescribing providers and pharmacists managing member prescriptions.

Policy Summary

PayerCapital Bluecross

PolicyAdvantage - Opioid drug list update

Policy CodePolicy N/A

Change TypeAdministrative update — quantity limits listed

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionConsult the member's benefit information or contact Capital Bluecross to determine coverage and authorization requirements per the member's contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~60+products listed

severalzero-quantity (adult)

multiplewith adult & child limits

30 daysreporting period

Coverage Criteria Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

This policy lists opioid products with specific formulary quantity limits expressed as the maximum permitted per 30 days. Several high-strength formulations are restricted by an adult quantity limit of 0 (examples include multiple fentanyl transdermal strengths, select hydrocodone ER strengths, and certain high‑strength morphine ER formulations), indicating those strengths are not permitted under standard quantity limits. Lower‑strength or immediate‑release formulations retain nonzero limits (for example, fentanyl 12mcg/hr is limited to 10 patches/30 days, and hydrocodone/APAP 5/325mg tablets are limited to 40 tablets/30 days).

Some extended‑release, high‑strength products are assigned an adult quantity limit of 0 CAPSULES/30 DAYS (for example, morphine sulfate ER high‑strength capsules such as 90mg, 100mg, and 120mg), which effectively excludes those strengths from dispensing under the stated formulary quantity limits.

Product Listings and Reporting Period

Analgesics - Opioid (Quantity limits per 30 days)mixed

OXMORPHONE TAB HCL 5MG	oxymorphone tablet hydrochloride 5 mg — Adult: 15 TABLETS/30 DAYS; Child: 9 TABLETS/30 DAYS
OXMORPHONE TAB HCL 10MG	oxymorphone tablet hydrochloride 10 mg — Adult: 5 TABLETS/30 DAYS; Child: 3 TABLETS/30 DAYS
TRAMADOL/APAP TAB 37.5-325	tramadol/hydrocodone? (tramadol/acetaminophen) tablet 37.5/325 mg — Adult: 40 TABLETS/30 DAYS; Child: 24 TABLETS/30 DAYS
TRAMADOL HCL CAP ER 100MG	tramadol HCl ER capsule 100 mg — Adult: 30 CAPSULES/30 DAYS; Child: NA
TRAMADOL HCL CAP ER 200MG	tramadol HCl ER capsule 200 mg — Adult: 30 CAPSULES/30 DAYS; Child: NA
TRAMADOL HCL CAP ER 300MG	tramadol HCl ER capsule 300 mg — Adult: 30 CAPSULES/30 DAYS; Child: NA
TRAMADOL HCL TAB 100MG ER	tramadol HCl ER tablet 100 mg — Adult: 30 TABLETS/30 DAYS; Child: NA
TRAMADOL HCL TAB 200MG ER	tramadol HCl ER tablet 200 mg — Adult: 30 TABLETS/30 DAYS; Child: NA
TRAMADOL HCL TAB 300MG ER	tramadol HCl ER tablet 300 mg — Adult: 30 TABLETS/30 DAYS; Child: NA
TRAMADOL HCL TAB 50MG	tramadol HCl tablet 50 mg — Adult: 50 TABLETS/30 DAYS; Child: 30 TABLETS/30 DAYS

1–10 of 11

1/2

Reporting period

Reporting periodper 30 days

Actions for Providers and Pharmacists

Prior Authorization

Prior Authorization Determined by Contract

Prior authorization requirements depend on the member's contract and may vary by plan. Providers and pharmacists should verify whether prior authorization is required for a specific prescription based on the member's benefit plan or contract.

Prior authorization determined by contract — follow the member's benefit contract for PA rules.

Billing Rule

Quantity Limits and Potential Prior Authorization

Dispensing quantities are subject to quantity limits shown in the formulary/coverage key. Prescriptions that exceed the stated quantity limits (for example limits expressed as X units/30 days) may be reduced at the point of sale, denied, or require prior authorization.

Quantity limits apply per 30-day period (examples shown in policy key).
Requests exceeding quantity limits may require prior authorization or may be non-covered.

Note

Benefit Determination

Coverage of the medication is determined by the member's individual or group contract. The presence of this policy does not guarantee that a drug is a covered benefit for a given member.

Benefit determinations must be based on the applicable contract/certificate of coverage.
Members and providers should consult member benefit information or contact Capital BlueCross for coverage questions (see member contact information).

Note

Consult Member Benefits / Member Benefit Verification

Consult the member's benefit information or contact Capital BlueCross to confirm coverage, benefit limits, and prior authorization requirements before prescribing or dispensing.

Refer to the member's contract/certificate of coverage for specific benefits and limitations.
For questions about coverage for fully insured Pennsylvania plans, call 800.962.2242 or the number on the member's ID card (TTY: 711).

Background

This document is an administrative update that defines formulary quantity limits for opioid products effective January 1, 2025. The listing includes adult and child limits per 30 days for multiple formulations and explicitly marks several high‑strength extended‑release products with an adult quantity limit of 0, reflecting those strengths are not permitted under the standard quantity limits.

Naming & Terms

inv-14: Naming key

Naming keyUPPERCASE = Brand; lowercase = Generic

Source example - BrandACTIQ LOZ (uppercase indicates brand)

Source example - Genericfentanyl dis (lowercase indicates generic)

inv-15: Definition of Quantity limit

DefinitionMaximum tablets, capsules, or milliliters of a listed formulation allowed per 30-day period for adults and children

Reporting periodPer 30 days (monthly)

ApplicabilityLimits shown separately for adult and child where provided

Step	Note
1	Different strengths and formulations of listed opioid products have different quantity limits; lower‑strength or immediate‑release (IR) products generally have nonzero monthly limits while certain high‑strength extended‑release (ER) formulations show an adult quantity limit of 0 (no units allowed per 30 days).

Opioid Product Quantity Limits (per 30 days)

inv-17: ACTIQ LOZ (200-1600MCG) — 120 LOZENGS

ProductACTIQ LOZ (200-1600MCG)

Adult quantity limit120 LOZENGS/30 DAYS

Child quantity limitNA (not applicable)

inv-18: APAP-CAFFEINE CAP (DIHYDROCODEINE) — 50 CAPSULES

ProductAPAP-CAFFEINE CAP (DIHYDROCODEINE)

Adult quantity limit50 CAPSULES/30 DAYS

Child quantity limit30 CAPSULES/30 DAYS

inv-19: fentanyl dis 12mcg/hr — 10 PATCHES

Productfentanyl dis 12mcg/hr

Adult quantity limit10 PATCHES/30 DAYS

Child quantity limitNA (not applicable)

inv-20: fentanyl dis 25-100mcg/hr (selected strengths) — 0 PATCHES

Productfentanyl dis 25-100mcg/hr (selected strengths)

Adult quantity limit0 PATCHES/30 DAYS

NoteMultiple mid-to-high strengths (25–100 mcg/hr) listed with 0 allowed per 30 days

inv-21: FENTORA (100-800MCG) — 120 TABS

ProductFENTORA (100-800MCG)

Adult quantity limit120 TABS/30 DAYS

Child quantity limitNA (not applicable)

inv-22: hydrocodone/apap liquids — 450 MLS

Producthydrocodone/apap liquids (e.g., 5-217 mg or 7.5-325 mg)

Adult quantity limit450 MLS/30 DAYS

Child quantity limit270 MLS/30 DAYS

inv-23: hydrocodone/apap tablets (5-325mg) — 40 TABLETS

Producthydrocodone/apap tablets (5-325mg)

Adult quantity limit40 TABLETS/30 DAYS

Child quantity limit24 TABLETS/30 DAYS

inv-24: hydrocodone ER 60-120mg — 0 TABLETS

Producthydrocodone ER 60-120mg

Adult quantity limit0 TABLETS/30 DAYS

Child quantity limitNA (not applicable)

inv-25: hydromorphone tablets (2-8mg) — varies by strength (e.g., 2mg=30 tabs; 8mg=5 tabs)

Producthydromorphone tablets (2-8mg)

Adult quantity limitsVaries by strength (e.g., 2mg = 30 TABLETS/30 DAYS; 4mg = 15 TABLETS/30 DAYS; 8mg = 5 TABLETS/30 DAYS)

Child quantity limitsExamples: 2mg = 18 TABLETS/30 DAYS; 4mg = 9 TABLETS/30 DAYS; 8mg = 3 TABLETS/30 DAYS

inv-26: METHADONE SOL 5MG/5ML — 300 MLS

ProductMETHADONE SOL 5MG/5ML

Adult quantity limit300 MLS/30 DAYS

Child quantity limitNA (not applicable)

inv-27: METHADONE SOL 10MG/5ML — 150 MLS

ProductMETHADONE SOL 10MG/5ML

Adult quantity limit150 MLS/30 DAYS

Child quantity limitNA (not applicable)

inv-28: Morphine sulfate ER high strengths (60mg and above, and select ER strengths) — 0 CAPSULES/TABLETS

ProductMorphine sulfate ER high strengths (60mg and above, and select ER strengths)

Adult quantity limit0 CAPSULES/TABLETS/30 DAYS

ImplicationHigh-strength ER morphine formulations are not permitted under the listed monthly quantity limits

inv-29: MORPHINE SULFATE SOL 10MG/5ML — 125

ProductMORPHINE SULFATE SOL 10MG/5ML

Adult quantity limit125 MLS/30 DAYS

Child quantity limit75 MLS/30 DAYS

inv-30: MORPHINE SULFATE TAB 15MG — 15

ProductMORPHINE SULFATE TAB 15MG

Adult quantity limit15 TABLETS/30 DAYS

Child quantity limit9 TABLETS/30 DAYS

inv-31: NUCYNTA TAB 50MG — 10

ProductNUCYNTA TAB 50MG

Adult quantity limit10 TABLETS/30 DAYS

Child quantity limit6 TABLETS/30 DAYS

inv-32: OXYCODONE SOL 5MG/5ML — 165

ProductOXYCODONE SOL 5MG/5ML

Adult quantity limit165 MLS/30 DAYS

Child quantity limit100 MLS/30 DAYS

inv-33: OXYCONTIN TAB 15MG ER — 60

ProductOXYCONTIN TAB 15MG ER

Adult quantity limit60 TABLETS/30 DAYS

Child quantity limitNA (not applicable)

inv-34: QDOLO SOL 5MG/ML — 400

ProductQDOLO SOL 5MG/ML

Adult quantity limit400 MLS/30 DAYS

Child quantity limit240 MLS/30 DAYS

inv-35: TRAMADOL HCL CAP ER 100MG — 30

ProductTRAMADOL HCL CAP ER 100MG

Adult quantity limit30 CAPSULES/30 DAYS

Child quantity limitNA (not applicable)

inv-36: TREZIX CAP — 50

ProductTREZIX CAP

Adult quantity limit50 CAPSULES/30 DAYS

Child quantity limit30 CAPSULES/30 DAYS

inv-37: XTAMPZA ER CAP 36MG — 0

ProductXTAMPZA ER CAP 36MG

Adult quantity limit0 CAPSULES/30 DAYS

Child quantity limitNA (not applicable)

Policy Summary

PayerCapital Bluecross

PolicyAdvantage - Opioid drug list update

Policy CodePolicy N/A

Change TypeAdministrative update — quantity limits listed

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionConsult the member's benefit information or contact Capital Bluecross to determine coverage and authorization requirements per the member's contract.

SourceLink

On This Page

OpenPayer

Advantage - Opioid drug list update

Coverage Criteria Summary

Product Listings and Reporting Period

Actions for Providers and Pharmacists

Background

Naming & Terms

Step Therapy Notes

Opioid Product Quantity Limits (per 30 days)

Revision History