Advantage - Opioid drug list update
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria Summary
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
| 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 |
Actions for Providers and Pharmacists
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.
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.
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).
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
Step Therapy Notes
| 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)
Revision History
Policy effective date for the Advantage opioid drug list update; formulary quantity limits for listed opioid products apply starting this date.
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