CurrentCapital BluecrossPolicy N/A

Opioid drug list and quantity limits (pharmacy)

Pharmacy policy listing opioids with associated adult and child quantity limits and indicating benefit determinations are subject to member contract; applies to pharmacy benefit determinations and prior authorization processes for members of Capital BlueCross.

Policy Summary

PayerCapital Bluecross

PolicyOpioid drug list and quantity limits (pharmacy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateEffective January 1, 2025

Next Review DateN/A

Key ActionVerify member benefits and authorization requirements with the plan before prescribing or dispensing listed opioids.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+opioid drug formulations listed (approximate)

5 Daysquantity limit timeframe referenced

Adult / Childseparate quantity limits provided for adult and child

PA-specific noticePA notice

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 formulations with specified adult quantity limits. Several high-strength, extended‑release or high‑dose formulations are effectively restricted by an Adult Quantity Limit = 0. Examples include high‑strength morphine ER capsules (e.g., MORPHINE SULFATE CAP 60MG ER and 80MG ER) and high‑strength oxycodone ER tablets (e.g., OXYCONTIN TAB 60MG ER and 80MG ER), which are shown with 0 TABLETS/30 DAYS or 0 CAPSULES/30 DAYS in the adult limits. The list also contains many formulations with specific nonzero adult limits (for example, APAP/CODEINE SOL 120-12/5 — 450 MLS/30 DAYS, apap/codeine tab 300-15mg — 30 TABLETS/30 DAYS, and fentanyl dis 12mcg/hr — 10 PATCHES/30 DAYS).

Quantity limits in the policy use the label "5 Days" as the timeframe descriptor with a measurement period of 30 DAYS for adult limits; child limits frequently use a "3 Days" label or are marked NA where not applicable.

Provider Actions & Notices

Prior Authorization

Prior Authorization May Be Required

Some pharmaceuticals may require prior authorization depending on the member's contract. Verify plan-specific requirements before prescribing or dispensing to avoid claim denials.

May apply to formulary-excluded or restricted opioids
Authorization requirements vary by member plan

Note

Check Member Benefits

Confirm benefit coverage and any restrictions with the member's benefit plan prior to providing medication or submitting claims.

Coverage, exclusions, and limits are determined by the member's contract

Note

Consult Member Benefit Information

Members and providers should consult the member's benefit information or contact the plan for benefit details, including coverage, limits, and prior authorization requirements.

Contact member services or review the plan's pharmacy benefit documentation for authorization criteria

Denial Risk

Benefit Determination Governs Coverage

Coverage is governed by the member's individual or group contract; this pharmacy policy does not guarantee coverage. Services may be denied if excluded by the member's benefit plan.

Benefit determinations are based on applicable contract language
Pharmacy policies are not a description of benefits

Background

This document functions as a formulary‑style opioid drug list intended to guide dispensing under the pharmacy benefit by specifying per‑drug quantity limits for adult and child populations. It is not clinical treatment guidance but provides discrete quantity thresholds (for example, multiple agents are listed with adult limits expressed as volumes, tablet counts, or patch counts).

Providers should note that quantity limits vary by formulation and strength; some pediatric limits are marked NA where not applicable. Also recognize that benefit determinations remain subject to the member's contract and authorization requirements may apply for certain products—verify member benefits and any prior authorization needs with the plan before dispensing.

Drug-Specific Quantity Limits (Adult / Child)

APAP/CODEINE SOL 120-12/5

APAP/CODEINE SOL 120-12/5 — Adult Quantity Limit450 MLS per 30 DAYS

APAP/CODEINE SOL 120-12/5 — Child Quantity Limit270 MLS per 30 DAYS

apap/codeine tab 300-15mg

apap/codeine tab 300-15mg — Adult Quantity Limit30 TABLETS per 30 DAYS

apap/codeine tab 300-15mg — Child Quantity Limit18 TABLETS per 30 DAYS

fentanyl dis 12mcg/hr

fentanyl dis 12mcg/hr — Adult Quantity Limit10 PATCHES per 30 DAYS

fentanyl dis 12mcg/hr — Child Quantity LimitNA

hydrocodone/apap sol 5-217mg

hydrocodone/apap sol 5-217mg — Adult Quantity Limit450 MLS per 30 DAYS

hydrocodone/apap sol 5-217mg — Child Quantity Limit270 MLS per 30 DAYS

methadone sol 5mg/5ml

methadone sol 5mg/5ml — Adult Quantity Limit300 MLS per 30 DAYS

methadone (tab) related limitsmethadone tab 5mg = 60 TABLETS per 30 DAYS (see source)

oxycodone/apap tab 2.5-325mg

oxycodone/apap tab 2.5-325mg — Adult Quantity Limit60 TABLETS per 30 DAYS

oxycodone/apap tab 2.5-325mg — Child Quantity Limit36 TABLETS per 30 DAYS

tramadol hcl tab 50mg

tramadol hcl tab 50mg — Adult Quantity Limit50 TABLETS per 30 DAYS

Related tramadol ER limits (context)TRAMADOL HCL TAB 100/200/300MG ER = 30 TABLETS per 30 DAYS (see source)