CurrentCapital BluecrossPolicy N/A
Value Plus - Opioid drug list update
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This pharmacy policy lists opioid medications and specifies adult and child quantity limits per 30 days for members under the Value Plus plan; benefit coverage depends on each member's contract and this document does not itself guarantee benefit coverage.
Policy Summary
PayerCapital Bluecross
PolicyValue Plus - Opioid drug list update
Policy CodePolicy N/A
Change TypeAdministrative — no material coverage changes
Effective DateJan 1, 2025
Next Review DateN/A
Key ActionConfirm member coverage by checking the individual contract; pharmacy policies do not determine benefit eligibility or authorization requirements.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
~120line items (approx.)
5 Daysadult timeframe
3 Dayschild timeframe
NAchild limits NA
Opioid Quantity Limits (Per Product)
Opioid quantity limits per product
Per-product adult and child quantity limits (Adult Quantity Limit = 5 Days, expressed per 30 days; Child Quantity Limit = 3 Days, expressed per 30 days). NA indicates not applicable.
APAP/CODEINE SOL 120-12/5 — Adult Quantity Limit 5 Days = 450 MLS/30 DAYS; Child Quantity Limit 3 Days = 270 MLS/30 DAYS.
APAP/CODEINE SOL 300-30MG — Adult Quantity Limit 5 Days = 450 MLS/30 DAYS; Child Quantity Limit 3 Days = 270 MLS/30 DAYS.
apap/codeine tab 300-15mg — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS.
apap/codeine tab 300-30mg — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS.
apap/codeine tab 300-60mg — Adult Quantity Limit 5 Days = 25 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 15 TABLETS/30 DAYS.
butorphanol sol 10mg/ml — Adult Quantity Limit 5 Days = 2.5 MLS/30 DAYS; Child Quantity Limit 3 Days = 0 MLS/30 DAYS.
codeine sulfate tab 30mg — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS.
codeine/apap tab 60-300mg — Adult Quantity Limit 5 Days = 25 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 15 TABLETS/30 DAYS.
endocet tab 2.5-325mg — Adult Quantity Limit 5 Days = 60 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 36 TABLETS/30 DAYS.
endocet tab 5-325mg — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS.
endocet tab 7.5-325mg — Adult Quantity Limit 5 Days = 20 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 12 TABLETS/30 DAYS.
endocet tab 10-325mg — Adult Quantity Limit 5 Days = 15 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 9 TABLETS/30 DAYS.
fentanyl dis 12mcg/hr — Adult Quantity Limit 5 Days = 10 PATCHES/30 DAYS; Child Quantity Limit 3 Days = NA.
fentanyl dis 25mcg/hr — Adult Quantity Limit 5 Days = 0 PATCHES/30 DAYS; Child Quantity Limit 3 Days = NA.
fentanyl dis 50mcg/hr — Adult Quantity Limit 5 Days = 0 PATCHES/30 DAYS; Child Quantity Limit 3 Days = NA.
fentanyl dis 75mcg/hr — Adult Quantity Limit 5 Days = 0 PATCHES/30 DAYS; Child Quantity Limit 3 Days = NA.
fentanyl dis 100mcg/hr — Adult Quantity Limit 5 Days = 0 PATCHES/30 DAYS; Child Quantity Limit 3 Days = NA.
FENTANYL OT LOZ 200MCG — Adult Quantity Limit 5 Days = 120 LOZNGS/30 DAYS; Child Quantity Limit 3 Days = NA.
FENTANYL OT LOZ 400MCG — Adult Quantity Limit 5 Days = 120 LOZNGS/30 DAYS; Child Quantity Limit 3 Days = NA.
FENTANYL OT LOZ 600MCG — Adult Quantity Limit 5 Days = 120 LOZNGS/30 DAYS; Child Quantity Limit 3 Days = NA.
FENTANYL OT LOZ 800MCG — Adult Quantity Limit 5 Days = 120 LOZNGS/30 DAYS; Child Quantity Limit 3 Days = NA.
FENTANYL OT LOZ 1200MCG — Adult Quantity Limit 5 Days = 120 LOZNGS/30 DAYS; Child Quantity Limit 3 Days = NA.
FENTANYL OT LOZ 1600MCG — Adult Quantity Limit 5 Days = 120 LOZNGS/30 DAYS; Child Quantity Limit 3 Days = NA.
hydrocodone/apap sol 5-217mg — Adult Quantity Limit 5 Days = 450 MLS/30 DAYS; Child Quantity Limit 3 Days = 270 MLS/30 DAYS.
hydrocodone/apap sol 7.5-325 — Adult Quantity Limit 5 Days = 450 MLS/30 DAYS; Child Quantity Limit 3 Days = 270 MLS/30 DAYS.
hydrocodone/apap tab 5-325mg — Adult Quantity Limit 5 Days = 40 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 24 TABLETS/30 DAYS.
hydrocodone/apap tab 7.5-325 — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS.
hydrocodone/apap tab 10-325mg — Adult Quantity Limit 5 Days = 25 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 15 TABLETS/30 DAYS.
hydrocodone/ibuprofen tab 7.5-200mg — Adult Quantity Limit 5 Days = 25 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 15 TABLETS/30 DAYS.
hydromorphone liq 1mg/ml — Adult Quantity Limit 5 Days = 60 MLS/30 DAYS; Child Quantity Limit 3 Days = 36 MLS/30 DAYS.
hydromorphone tab 2mg — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS.
hydromorphone tab 4mg — Adult Quantity Limit 5 Days = 15 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 9 TABLETS/30 DAYS.
hydromorphone tab 8mg — Adult Quantity Limit 5 Days = 5 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 3 TABLETS/30 DAYS.
methadone sol 5mg/5ml — Adult Quantity Limit 5 Days = 300 MLS/30 DAYS; Child Quantity Limit 3 Days = NA.
methadone sol 10mg/5ml — Adult Quantity Limit 5 Days = 150 MLS/30 DAYS; Child Quantity Limit 3 Days = NA.
methadone tab 5mg — Adult Quantity Limit 5 Days = 60 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
methadone tab 10mg — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
morphine sulfate sol 10mg/5ml — Adult Quantity Limit 5 Days = 125 MLS/30 DAYS; Child Quantity Limit 3 Days = 75 MLS/30 DAYS.
morphine sulfate sol 20mg/ml — Adult Quantity Limit 5 Days = 15 MLS/30 DAYS; Child Quantity Limit 3 Days = 15 MLS/30 DAYS.
morphine sulfate sol 100/5ml — Adult Quantity Limit 5 Days = 15 MLS/30 DAYS; Child Quantity Limit 3 Days = 15 MLS/30 DAYS.
morphine sulfate tab 15mg — Adult Quantity Limit 5 Days = 15 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 9 TABLETS/30 DAYS.
morphine sulfate tab 30mg — Adult Quantity Limit 5 Days = 5 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 3 TABLETS/30 DAYS.
morphine sulfate tab 100mg cr — Adult Quantity Limit 5 Days = 0 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
morphine sulfate tab 15mg er — Adult Quantity Limit 5 Days = 60 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
morphine sulfate tab 30mg er — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
morphine sulfate tab 60mg er — Adult Quantity Limit 5 Days = 0 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
morphine sulfate tab 100mg er — Adult Quantity Limit 5 Days = 0 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
morphine sulfate tab 200mg er — Adult Quantity Limit 5 Days = 0 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
oxycodone/apap tab 2.5-325 — Adult Quantity Limit 5 Days = 60 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 36 TABLETS/30 DAYS.
oxycodone/apap tab 5-325mg — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS.
oxycodone/apap tab 7.5-325 — Adult Quantity Limit 5 Days = 20 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 12 TABLETS/30 DAYS.
oxycodone/apap tab 10-325mg — Adult Quantity Limit 5 Days = 15 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 9 TABLETS/30 DAYS.
oxycodone con 10/0.5ml — Adult Quantity Limit 5 Days = 5 MLS/30 DAYS; Child Quantity Limit 3 Days = 3 MLS/30 DAYS.
oxycodone con 100/5ml — Adult Quantity Limit 5 Days = 5 MLS/30 DAYS; Child Quantity Limit 3 Days = 3 MLS/30 DAYS.
oxycodone sol 5mg/5ml — Adult Quantity Limit 5 Days = 165 MLS/30 DAYS; Child Quantity Limit 3 Days = 100 MLS/30 DAYS.
oxycodone tab 5mg — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS.
oxycodone tab 10mg — Adult Quantity Limit 5 Days = 15 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 9 TABLETS/30 DAYS.
oxycodone tab 15mg — Adult Quantity Limit 5 Days = 10 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 6 TABLETS/30 DAYS.
oxycodone tab 20mg — Adult Quantity Limit 5 Days = 5 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 3 TABLETS/30 DAYS.
oxycodone tab 30mg — Adult Quantity Limit 5 Days = 5 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 3 TABLETS/30 DAYS.
oxymorphone tab hcl 5mg — Adult Quantity Limit 5 Days = 15 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 9 TABLETS/30 DAYS.
oxymorphone tab hcl 10mg — Adult Quantity Limit 5 Days = 5 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 3 TABLETS/30 DAYS.
tramadol/apap tab 37.5-325 — Adult Quantity Limit 5 Days = 40 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 24 TABLETS/30 DAYS.
tramadol hcl tab 50mg — Adult Quantity Limit 5 Days = 50 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 30 TABLETS/30 DAYS.
tramadol hcl tab 100mg er — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
tramadol hcl tab 200mg er — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
tramadol hcl tab 300mg er — Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = NA.
Codes and Timeframe Key Values
Opioid medication quantity limitsNDC
| APAP/CODEINE SOL 120-12/5 | ANALGESICS - OPIOID |
| APAP/CODEINE SOL 300-30MG | ANALGESICS - OPIOID |
| apap/codeine tab 300-15mg | ANALGESICS - OPIOID |
| apap/codeine tab 300-30mg | ANALGESICS - OPIOID |
| apap/codeine tab 300-60mg | ANALGESICS - OPIOID |
| butorphanol sol 10mg/ml | ANALGESICS - OPIOID |
| codeine sulfate tab 30mg | ANALGESICS - OPIOID |
| codeine/apap tab 60-300mg | ANALGESICS - OPIOID |
Opioid medication quantity limits (continued)NDC
| No codes listed |
Adult quantity limit timeframe
Adult quantity limit timeframe5 Days (expressed as quantity per 30 days)
Expression formatShown on line items as 'Adult Quantity Limit 5 Days = X /30 DAYS'
Applies toPer-product adult limits across opioid list (e.g., APAP/CODEINE SOL 120-12/5: 5 Days = 450 MLS/30 DAYS)
Child quantity limit timeframe
Child quantity limit timeframe3 Days (expressed as quantity per 30 days)
Expression formatShown on line items as 'Child Quantity Limit 3 Days = Y /30 DAYS' or 'NA' when not applicable
ExampleAPAP/CODEINE SOL 120-12/5: Child 3 Days = 270 MLS/30 DAYS; fentanyl patches may show 'NA' for child limits
Benefit Determination and Authorization
Prior Authorization
Benefit determination and authorization note
The existence of this pharmacy policy does not mean the service is a covered benefit under the member's contract. Benefit determinations must be based on the applicable member contract language. Pharmacy policies do not constitute a description of benefits. A member's individual or group benefits govern which pharmaceuticals are covered, which are excluded, which are subject to benefit limits, and which require authorization. Members and providers should consult the member's benefit information or contact Capital BlueCross for benefit details and prior authorization requirements.
- Benefit determinations depend on the member's contract
- Prior authorization requirements vary by member plan
- Pharmacy policies do not guarantee coverage
Name Key
Name key
Name key conventionUPPERCASE names = Brand; lowercase names = Generic
Usage in documentApplied consistently in medication list to distinguish brand vs. generic entries
Source noteListed under 'Key' at start of drug list
Policy Summary
PayerCapital Bluecross
PolicyValue Plus - Opioid drug list update
Policy CodePolicy N/A
Change TypeAdministrative — no material coverage changes
Effective DateJan 1, 2025
Next Review DateN/A
Key ActionConfirm member coverage by checking the individual contract; pharmacy policies do not determine benefit eligibility or authorization requirements.
SourceLink
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