CurrentCapital BlueCrossPolicy N/A

Value Plus Opioid drug list update

Defines the Value Plus opioid medication formulary entries and associated adult and child quantity limits per 30 days; intended for pharmacy benefit administrators, prescribing providers, and pharmacies under Capital BlueCross member plans.

Policy Summary

PayerCapital BlueCross

PolicyValue Plus Opioid drug list update

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review Date

Key ActionConsult the member's benefit information or contact the payer because benefit determination depends on the member contract and this policy does not guarantee coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-01-01policy effective date

multiplelisted with quantity limits

includedadult & child limits

appliesPA fully insured notice

Product Quantity Limits and Coverage Rules

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.

Product quantity limits

Per-product quantity limits are stated below. Adult entries correspond to a 5-day supply and child entries correspond to a 3-day supply. Consult the member's benefits to determine whether a product is covered and any additional limits or exclusions.

Limits apply per product, as listed below, and are applied per 30 days; consult member benefit for coverage determination and any additional restrictions.

Product limits (examples from formulary)

APAPICODEINE (liquid and tablets)
- APAPICODEINE SOL 120-12/5 — Adult Quantity Limit (5 Days) = 450 mL per 30 days; Child Quantity Limit (3 Days) = 270 mL per 30 days.
- APAPICODEINE TAB 300-15 mg — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = 18 tablets per 30 days.
- APAPICODEINE TAB 300-30 mg — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = 18 tablets per 30 days.
- APAPICODEINE TAB 300-60 mg — Adult Quantity Limit (5 Days) = 25 tablets per 30 days; Child Quantity Limit (3 Days) = 15 tablets per 30 days.
ENDOCET (tablets)
- ENDOCET TAB 2.5-325 mg — Adult Quantity Limit (5 Days) = 60 tablets per 30 days; Child Quantity Limit (3 Days) = 36 tablets per 30 days.
- ENDOCET TAB 5-325 mg — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = 18 tablets per 30 days.
- ENDOCET TAB 7.5-325 mg — Adult Quantity Limit (5 Days) = 20 tablets per 30 days; Child Quantity Limit (3 Days) = 12 tablets per 30 days.
- ENDOCET TAB 10-325 mg — Adult Quantity Limit (5 Days) = 15 tablets per 30 days; Child Quantity Limit (3 Days) = 9 tablets per 30 days.
FENTANYL (patches and lozenges)
- FENTANYL DIS 12 mcg/hr — Adult Quantity Limit (5 Days) = 10 patches per 30 days; Child Quantity Limit (3 Days) = NA.
- FENTANYL DIS 25/50/75 mcg/hr — Adult Quantity Limit (5 Days) = 0 patches per 30 days; Child Quantity Limit (3 Days) = NA.
- FENTANYL OT LOZ (multiple strengths) — Adult Quantity Limit (5 Days) = 120 lozenges per 30 days; Child Quantity Limit (3 Days) = NA.
HYDROCODONE combinations (liquid and tablets)
- HYDROCODONE/APAP SOL 5-217 mg and 7.5-325 mg — Adult Quantity Limit (5 Days) = 450 mL per 30 days; Child Quantity Limit (3 Days) = 270 mL per 30 days.
- HYDROCODONE/APAP TAB 5-325 mg — Adult Quantity Limit (5 Days) = 40 tablets per 30 days; Child Quantity Limit (3 Days) = 24 tablets per 30 days.
- HYDROCODONE/APAP TAB 7.5-325 mg — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = 18 tablets per 30 days.
- HYDROCODONE/APAP TAB 10-325 mg — Adult Quantity Limit (5 Days) = 25 tablets per 30 days; Child Quantity Limit (3 Days) = 15 tablets per 30 days.
HYDROMORPHONE (liquid and tablets)
- HYDROMORPHONE LIQ 1 mg/mL — Adult Quantity Limit (5 Days) = 60 mL per 30 days; Child Quantity Limit (3 Days) = 36 mL per 30 days.
- HYDROMORPHONE TAB 2 mg — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = 18 tablets per 30 days.
- HYDROMORPHONE TAB 4 mg — Adult Quantity Limit (5 Days) = 15 tablets per 30 days; Child Quantity Limit (3 Days) = 9 tablets per 30 days.
- HYDROMORPHONE TAB 8 mg — Adult Quantity Limit (5 Days) = 5 tablets per 30 days; Child Quantity Limit (3 Days) = 3 tablets per 30 days.
METHADONE (solutions and tablets)
- METHADONE SOL 5 mg/mL — Adult Quantity Limit (5 Days) = 300 mL per 30 days; Child Quantity Limit (3 Days) = NA.
- METHADONE SOL 10 mg/mL — Adult Quantity Limit (5 Days) = 150 mL per 30 days; Child Quantity Limit (3 Days) = NA.
- METHADONE TAB 10 mg — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = NA.
MORPHINE (solutions and tablets)
- MORPHINE SULFATE SOL 20 mg/mL and 100/5 mL — Adult Quantity Limit (5 Days) = 15 mL per 30 days; Child Quantity Limit (3 Days) = 15 mL per 30 days.
- MORPHINE SULFATE TAB 30 mg — Adult Quantity Limit (5 Days) = 5 tablets per 30 days; Child Quantity Limit (3 Days) = 3 tablets per 30 days.
- MORPHINE SULFATE TAB 5 mg ER — Adult Quantity Limit (5 Days) = 60 tablets per 30 days; Child Quantity Limit (3 Days) = NA.
- MORPHINE SULFATE TAB 30 mg ER — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = NA.
OXYCODONE (various formulations)
- OXYCODONE/APAP TAB 2.5-325 mg — Adult Quantity Limit (5 Days) = 60 tablets per 30 days; Child Quantity Limit (3 Days) = 36 tablets per 30 days.
- OXYCODONE/APAP TAB 5-325 mg — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = 18 tablets per 30 days.
- OXYCODONE/APAP TAB 7.5-325 mg — Adult Quantity Limit (5 Days) = 20 tablets per 30 days; Child Quantity Limit (3 Days) = 12 tablets per 30 days.
- OXYCODONE TAB 5 mg — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = 18 tablets per 30 days.
- OXYCODONE TAB 10 mg — Adult Quantity Limit (5 Days) = 15 tablets per 30 days; Child Quantity Limit (3 Days) = 9 tablets per 30 days.
OXYCODONE (concentrations and solutions)
- OXYCODONE CON 10/0.5 mL and CON 100/5 mL — Adult Quantity Limit (5 Days) = 5 mL per 30 days; Child Quantity Limit (3 Days) = 3 mL per 30 days.
- OXYCODONE SOL 5 mg/5 mL — Adult Quantity Limit (5 Days) = 165 mL per 30 days; Child Quantity Limit (3 Days) = 100 mL per 30 days.
OXYMORPHONE (tablets)
- OXYMORPHONE TAB HCL (various strengths) — Adult Quantity Limit (5 Days) ranges from 5–15 tablets per 30 days depending on strength; Child Quantity Limit (3 Days) ranges from 3–9 tablets per 30 days depending on strength.
TRAMADOL (immediate and extended release)
- TRAMADOL/APAP TAB 37.5-325 — Adult Quantity Limit (5 Days) = 40 tablets per 30 days; Child Quantity Limit (3 Days) = 24 tablets per 30 days.
- TRAMADOL HCL TAB 50 mg — Adult Quantity Limit (5 Days) = 50 tablets per 30 days; Child Quantity Limit (3 Days) = 30 tablets per 30 days.
- TRAMADOL HCL TAB 100 mg ER — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = NA.
- TRAMADOL HCL TAB 200 mg ER — Adult Quantity Limit (5 Days) = 30 tablets per 30 days; Child Quantity Limit (3 Days) = NA.

Formulary Entries and Quantity Specifications

Formulary entries (drug names and limits)NDC

APAPICODEINE SOL 120-12/5	Adult Quantity Limit 5 Days = 450 MLS/30 DAYS; Child Quantity Limit 3 Days = 270 MLS/30 DAYS
APAPICODEINE SOL 300-30MG	Adult Quantity Limit 5 Days = 450 MLS/30 DAYS; Child Quantity Limit 3 Days = (not specified)
apaplcodeine tab 300-15mg	Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS
apaplcodeine tab 300-30mg	Adult Quantity Limit 5 Days = 30 TABLETS/30 DAYS; Child Quantity Limit 3 Days = 18 TABLETS/30 DAYS
apaplcodeine 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
codeinelapap tab 60-300mg	Adult Quantity Limit 5 Days = 25 TABLETS/30 DAYS; Child Quantity Limit 3 Days = (truncated in source)

Quantity limits (units per 30 days)

APAPICODEINE SOL 120-12/5 (adult)450 mL per 30 days (5 Days)

APAPICODEINE SOL 120-12/5 (child)270 mL per 30 days (3 Days)

endocet tab 2.5/325 mg (adult)60 tablets per 30 days (5 Days)

endocet tab 2.5/325 mg (child)36 tablets per 30 days (3 Days)

fentanyl transdermal 12 mcg/hr (adult)10 patches per 30 days (5 Days)

hydrocodone/acetaminophen tab 10/325 mg (child)15 tablets per 30 days (3 Days)

tramadol ER 100 mg (adult)30 tablets per 30 days (5 Days)

OpenPayer

Value Plus Opioid drug list update

Product Quantity Limits and Coverage Rules

Formulary Entries and Quantity Specifications

Benefit Determination and Authorization

Naming Conventions