Exclusive - Opioid drug list and quantity limits
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Pharmacy policy listing opioids covered under the Exclusive benefit with per-product quantity limits for adult and child members; applies to benefit determinations and authorization processes for Capital Bluecross members in North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria and Quantity Limits
The existence of this pharmacy policy and the products listed herein does not guarantee that any specific drug is a covered benefit under a member's contract. Benefit determinations must be made based on the member's applicable contract language; pharmacy policies do not replace or define member benefits. Providers and members should consult the member's benefit information or contact the plan to confirm coverage, exclusions, benefit limits, and any authorization requirements.
Quantity limits (per-product)
Coverage subject to member contract; products are subject to the listed quantity limits:
See product-specific entries in the policy listing for exact limits
Provider Actions and Authorization Notes
Quantity limits enforceable by prior authorization
Per-product quantity limits (adult and child) listed in the policy are enforced; prior authorization may be required when a requested quantity exceeds the listed limit or when the member contract requires authorization.
- Examples include APAP/CODEINE SOL 120-12/5: Adult 5 Days = 450 MLS/30 DAYS; Child 3 Days = 270 MLS/30 DAYS.
- See product-specific listings for exact adult (5-day) and child (3-day) limits per 30 days.
Step therapy not specified
This policy does not list any step-therapy requirements; no explicit step-therapy steps are specified in the document.
Verify member benefits
Providers and members must consult the member's benefit information or contact the plan to determine whether a drug is a covered benefit and whether authorization is required.
- Pharmacy policies do not constitute a description of benefits — benefit determinations are based on the applicable contract language.
Benefit determination governs coverage
Coverage is governed by the member's individual or group contract language; the existence of this pharmacy policy does not guarantee a service is a covered benefit and lack of contract coverage may result in denial.
- A member's contract governs which pharmaceuticals are covered, excluded, subject to limits, or require authorization.
Policy Background
This policy functions as a formulary-style list of opioid products covered under the plan’s exclusive pharmacy benefit and specifies per-product quantity limits. For most adult prescriptions the policy uses a standard short-course measure of 5 Days (expressed per 30 days), and for pediatric prescriptions the policy commonly uses a 3 Days (expressed per 30 days) measure. Each listed product includes the exact adult and child quantity limits (for example, APAP/CODEINE SOL 120-12/5 – 450 MLS; endocet tab 2.5-325 – 60 TABLETS; hydrocodone/apap tab 5-325mg – 40 TABLETS; oxycodone tab 5mg – 30 TABLETS), and requests exceeding those per-product limits may require prior authorization or other benefit allowance under the member contract.
Term Definitions
Per-Product Quantity Limits (Selected Items)
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