CurrentCapital BluecrossPolicy N/A

Value Opioid drug list update

This pharmacy reimbursement/payment policy lists opioid products and the default quantity limits for adult and child members; it governs pharmacy dispensing limits but does not itself determine benefit coverage, which is defined by the member's contract.

Policy Summary

PayerCapital Bluecross

PolicyValue Opioid drug list update

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionMake benefit determinations based on the member's contract; pharmacy policies do not constitute a description of benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=1Opioid formulations listed

Adult/ChildAdult/Child limits present

2025-01-01Effective date

PAPA-specific notice

Opioid Product Quantity Limits

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.

APAPICODEINE SOL 120-12/5 — Adult Quantity_ 5 Days_ = 450 MLS/30 DAYS; Child Quantity_ 3 Days_ = 270 MLS/30 DAYS.

APAPICODEINE SOL 300-30MG — Adult Quantity_ 5 Days_ = 450 MLS/30 DAYS; Child Quantity_ 3 Days_ = 270 MLS/30 DAYS.

apaplcodeine tab 300-15mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 18 TABLETS/30 DAYS.

apaplcodeine tab 300-30mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 18 TABLETS/30 DAYS.

apaplcodeine tab 300-60mg — Adult Quantity_ 5 Days_ = 25 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 15 TABLETS/30 DAYS.

buprenorphine dis 5 mcg/hr — Adult Quantity_ 5 Days_ = 4 SYSTEMS/28 DAYS; Child Quantity_ 3 Days_ = NA.

buprenorphine dis 2.5 mcg/hr — Adult Quantity_ 5 Days_ = 4 SYSTEMS/28 DAYS; Child Quantity_ 3 Days_ = NA.

buprenorphine dis 10 mcg/hr — Adult Quantity_ 5 Days_ = 4 SYSTEMS/28 DAYS; Child Quantity_ 3 Days_ = NA.

butorphanol sol 10 mg/ml — Adult Quantity_ 5 Days_ = 2.5 MLS/30 DAYS; Child Quantity_ 3 Days_ = 0 MLS/30 DAYS.

codeine sulfate tab 30 mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 18 TABLETS/30 DAYS.

CODEINE SULFATE TAB 15 MG — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 18 TABLETS/30 DAYS.

CODEINE SULFATE TAB 60 MG — Adult Quantity_ 5 Days_ = 25 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 15 TABLETS/30 DAYS.

codeine/apap tab 60-300 mg — Adult Quantity_ 5 Days_ = 25 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 15 TABLETS/30 DAYS.

endocet tab 2.5-325 mg — Adult Quantity_ 5 Days_ = 60 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 36 TABLETS/30 DAYS.

endocet tab 5-325 mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 18 TABLETS/30 DAYS.

endocet tab 7.5-325 mg — Adult Quantity_ 5 Days_ = 20 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = (not specified).

endocet tab 10-325 mg — Adult Quantity_ 5 Days_ = 15 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 9 TABLETS/30 DAYS.

FENTANYL transdermal 12 mcg/hr — Adult Quantity_ 5 Days_ = 10 PATCHES/30 DAYS; Child Quantity_ 3 Days_ = NA.

FENTANYL transdermal higher strengths (50 mcg/hr and others) — Adult Quantity_ 5 Days_ = 0 PATCHES/30 DAYS; Child Quantity_ 3 Days_ = NA (restricted/not applicable).

FENTANYL OT LOZ 200–1600 MCG (various strengths) — Adult Quantity_ 5 Days_ = 120 LOZENGES/30 DAYS; Child Quantity_ 3 Days_ = NA.

hydrocodone/elapap solution 5-217 mg — Adult Quantity_ 5 Days_ = 450 MLS/30 DAYS; Child Quantity_ 3 Days_ = 270 MLS/30 DAYS.

hydrocodone/elapap solution 7.5-325 — Adult Quantity_ 5 Days_ = 450 MLS/30 DAYS; Child Quantity_ 3 Days_ = 270 MLS/30 DAYS.

hydrocodone/apap tab 5-325 mg — Adult Quantity_ 5 Days_ = 40 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 24 TABLETS/30 DAYS.

hydrocodone/apap tab 7.5-325 mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 18 TABLETS/30 DAYS.

hydrocodone/apap tab 10-325 mg — Adult Quantity_ 5 Days_ = 25 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = (not specified).

hydrocodone/ibuprofen tab 7.5-200 mg — Adult Quantity_ 5 Days_ = 25 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 15 TABLETS/30 DAYS.

hydromorphone liquid 1 mg/ml — Adult Quantity_ 5 Days_ = 60 MLS/30 DAYS; Child Quantity_ 3 Days_ = 36 MLS/30 DAYS.

hydromorphone tab 2 mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 18 TABLETS/30 DAYS.

hydromorphone tab 4 mg — Adult Quantity_ 5 Days_ = 15 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 9 TABLETS/30 DAYS.

hydromorphone tab 8 mg — Adult Quantity_ 5 Days_ = 5 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 3 TABLETS/30 DAYS.

hydromorphone ER 8 mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = NA.

hydromorphone ER 12 mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = NA.

hydromorphone ER 16 mg and 32 mg — Adult Quantity_ 5 Days_ = 0 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = NA (restricted).

meperidine tab 50 mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 30 TABLETS/30 DAYS.

methadone sol 5 mg/5 mL — Adult Quantity_ 5 Days_ = 300 MLS/30 DAYS; Child Quantity_ 3 Days_ = NA.

methadone tab 10 mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = NA.

MORPHINE SULFATE solutions and liquids — multiple strengths with adult and child quantities specified (examples: 10/0.5 mL Adult = 15 MLS/30 DAYS; Child = 15 MLS/30 DAYS; 10 mg/5 mL Adult = 125 MLS/30 DAYS; Child = 75 MLS/30 DAYS).

morphine sulfate tab 5 mg — Adult Quantity_ 5 Days_ = 15 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 9 TABLETS/30 DAYS.

morphine sulfate tab 30 mg — Adult Quantity_ 5 Days_ = 5 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 3 TABLETS/30 DAYS.

morphine sulfate ER high-strength tablets (60 mg, 200 mg, etc.) — Adult Quantity_ 5 Days_ = 0 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = NA (restricted).

NUCYNTA TAB 75 MG — Adult Quantity_ 5 Days_ = 5 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 3 TABLETS/30 DAYS.

NUCYNTA ER and higher-strength NUCYNTA formulations — some ER strengths have Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS or 0 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = NA for ER/higher strengths.

oxycodone/apap tab 2.5-325 — Adult Quantity_ 5 Days_ = 60 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 36 TABLETS/30 DAYS.

oxycodone/apap tab 5-325 — Adult Quantity_ 5 Days_ = 60 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 36 TABLETS/30 DAYS (duplicate listing present).

oxycodone/apap tab 5-325 variant — Adult Quantity_ 5 Days_ = 20 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 12 TABLETS/30 DAYS (specific variant entries).

oxycodone/apap tab 10-325 — Adult Quantity_ 5 Days_ = 15 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 9 TABLETS/30 DAYS.

oxycodone concentrated solutions and liquids — multiple entries with adult and child mL limits (examples provided in source).

oxycodone tab 5 mg — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 15 TABLETS/30 DAYS (examples of various oxycodone tablet strengths listed).

OXYCODONE ER and OXYCONTIN formulations — numerous ER strengths with adult quantities ranging from 0 to 60 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = NA for many ER strengths (some ER strengths restricted to 0).

OXYMORPHONE ER tablets — multiple strengths with adult quantities (examples: some strengths = 60 TABLETS/30 DAYS; others = 30 or 0); Child Quantity_ 3 Days_ = NA.

tramadol/apap tab 37.5-325 — Adult Quantity_ 5 Days_ = 40 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = (not specified).

TRAMADOL HCL TAB 100 MG ER — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = NA.

TRAMADOL HCL TAB 200 MG ER and 300 MG ER — Adult Quantity_ 5 Days_ = 30 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = NA.

tramadol HCL tab 50 mg — Adult Quantity_ 5 Days_ = 50 TABLETS/30 DAYS; Child Quantity_ 3 Days_ = 30 TABLETS/30 DAYS.

Many entries include 'NA' for Child Quantity_ 3 Days indicating not applicable or not available for pediatric use; some high‑strength or extended‑release formulations are restricted to zero quantity for adults.

Product List and Quantity Metadata

Opioid product list (no billing codes provided)mixed

APAPICODEINE SOL 120-12/5	ANALGESICS OPIOID
APAPICODEINE SOL 300-30MG	ANALGESICS OPIOID
apaplcodeine tab 300-75mg	ANALGESICS OPIOID
apaplcodeine tab 300-30mg	ANALGESICS OPIOID
apaplcodeine tab 300-60mg	ANALGESICS OPIOID
buprenorphine dis 5mcg/hr	ANALGESICS OPIOID
buprenorphine dis 25 mcg/hr	ANALGESICS OPIOID
buprenorphine dis 10mcg/hr	ANALGESICS OPIOID

Opioid product list (no billing codes provided) - continued quantitiesmixed

APAPICODEINE SOL 120-12/5 - Adult Quantity	450 MLS/30 DAYS; Child Quantity = 270 MLS/30 DAYS
APAPICODEINE SOL 300-30MG - Adult Quantity	450 MLS/30 DAYS; Child Quantity = 270 MLS/30 DAYS
apaplcodeine tab 300-75mg - Adult Quantity	30 TABLETS/30 DAYS; Child Quantity = 18 TABLETS/30 DAYS
apaplcodeine tab 300-30mg - Adult Quantity	30 TABLETS/30 DAYS; Child Quantity = 18 TABLETS/30 DAYS
apaplcodeine tab 300-60mg - Adult Quantity	25 TABLETS/30 DAYS; Child Quantity = 15 TABLETS/30 DAYS
buprenorphine dis 5mcg/hr - Adult Quantity	4 SYSTEMS/28 DAYS; Child Quantity = NA
buprenorphine dis 25 mcg/hr - Adult Quantity	4 SYSTEMS/28 DAYS; Child Quantity = NA
buprenorphine dis 10mcg/hr - Adult Quantity	4 SYSTEMS/28 DAYS

Quantity limits (per 30 days) - adult vs child

Adult default quantity per 30 daysVaries by product (examples: many liquid formulations = 450 mL/30 days; many tablets = 30–50 tablets/30 days; select ER products = 30 tablets/30 days)

Child default quantity per 30 daysVaries by product (examples: many liquid formulations = 270 mL/30 days; many tablets = 18–30 tablets/30 days; many ER products = NA)

LOZ/lozenge productsFentanyl lozenges: Adult = 120 lozenges/30 days; Child = NA

Patch / system productsBuprenorphine transdermal systems: Adult = 4 systems/28 days; Child = NA

Tramadol examplesTramadol HCl tab 50 mg: Adult = 50 tablets/30 days; Child = 30 tablets/30 days; Tramadol ER (100–300 mg): Adult = 30 tablets/30 days; Child = NA

OpenPayer

Value Opioid drug list update

Opioid Product Quantity Limits

Product List and Quantity Metadata

Benefit Determination and Authorization Notes

Name and Benefit Definitions