CurrentNeighborhood Health Plan of Rhode IslandPolicy 2221-M

Opioids IR - 7-Day Acute Pain Duration Limit with MME Limit and Post Limit

Defines product list, indications, and limitations of use for immediate-release opioid analgesics referenced by Neighborhood Health Plan of Rhode Island; affects prescribing and coverage of listed opioid tablets, solutions, suppositories and capsules for acute pain.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOpioids IR - 7-Day Acute Pain Duration Limit with MME Limit and Post Limit

Policy CodePolicy 2221-M

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization when a first-time opioid fill exceeds a 7-day supply or when requesting quantities above initial MME limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7-dayinitial max supply w/o PA

≤90 MME/dayinitial MME limit

≤200 MME/daypost MME limit

365 dayslookback (cancer/sickle/pall)

90 daysprior fill lookback

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8-daythreshold triggering initial limits

Coverage Criteria and Limits

General product coverage and limitations

Covered when ALL of the following are met (per product-specific indications and limitations of use):

Indication: Pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate

Supported across product sections

Use reservation: Opioid reserved for patients who have not tolerated or not responded adequately to non-opioid analgesics or opioid combination products

Repeated in Limitations of Use sections

Avoid extended use: Opioid should not be used for an extended period unless pain remains severe enough to require an opioid and alternatives continue to be inadequate

Stated in product Limitations of Use

Opioid quantity-limit and screen logic

Coverage and quantity-limit logic based on recent opioid use and presence of cancer/sickle cell/palliative care indicators

Screen-out for prescription benefit payment: If the patient has, within the past 365 days, (a) a prescription fill for a cancer or sickle cell drug, (b) an ICD‑10 diagnosis for cancer, sickle cell disease, or palliative care submitted with the prescription claim, (c) an ICD‑10 cancer or palliative care diagnosis in the member profile, (d) any history of an ICD‑10 diagnosis code indicating sickle cell disease in the member profile, or (e) a hospice patient residence code submitted with the prescription claim, then the requested drug will be paid under the prescription benefit (exempt from the opioid quantity‑limit path).365-day lookback

Based on claim or member‑profile evidence

Initial opioid-fill without prior opioid use: If the patient lacks the above screen‑out indicators AND does not have at least an 8‑day opioid fill in the past 90 days (i.e., first opioid fill), then an incoming prescription >7 days will reject and the patient may receive a 7‑day supply; a prior authorization may be submitted for additional quantity and PA criteria will be applied.no opioid fills >=8 days in past 90 days

First‑fill rules apply

Cancer / Sickle Cell / Terminal / Hospice / Palliative care

Authorization may be granted when the requested drug is prescribed for pain associated with one of these conditions.

Cancer / Sickle cell / Terminal / Hospice / Palliative care: Requested drug is prescribed for pain associated with cancer, sickle cell disease, a terminal condition, or pain being managed through hospice or palliative care.

Screen‑out routes drug to prescription benefit

Acute pain (non‑cancer/non‑sickle cell/non‑palliative/non‑hospice)

Authorization may be granted when ALL of the following are met for acute pain:

Acute pain criteria: 1) Patient can safely take the requested dose based on their history of opioid use (prescribe the lowest effective dose). 2) Patient has been evaluated and will be monitored regularly for development of opioid use disorder.

Many acute conditions require only a few days of opioids

Chronic pain

Authorization may be granted when ALL of the following are met for chronic pain:

Chronic pain criteria: 1) Patient can safely take the requested dose based on their history of opioid use. 2) Patient has been evaluated and will be monitored regularly for development of opioid use disorder. 3) Pain will be reassessed in the first month after the initial prescription or dose increase AND every 3 months thereafter demonstrating benefit that outweighs risks.

Chronic pain generally >3 months

Acute pain duration and initial quantity limits

Program logic and limits applied in sequence:

Sequencing: 1) Apply acute pain duration limit first: potential first fills limited to a maximum 7‑day supply per fill (up to 7 days of therapy in a 90‑day period). 2) Then apply initial quantity‑limit logic: coverage up to quantities corresponding to ≤90 MME/day per Columns A/B. 3) Exceeding the first‑time 7‑day limit or requesting quantities above initial limits requires prior authorization.7 days; ≤90 MME/day; ≤200 MME/day

Limits accumulate across drugs with same unit limit

Quantity limits by product and column

Covered when dispensed within the per-product, per-column quantity limits shown (Initial vs Post columns):

General rule: Each listed immediate‑release formulation is subject to columned limits: Column A (Initial 1 Month, per 25 days) and Column B (Initial 3 Month, per 75 days) cap at ≤90 MME/day; Column C (Post 1 Month) and Column D (Post 3 Month) cap at ≤200 MME/day.see product rows

Limits expressed as tablets/month or mL/month and as daily equivalents

Examples (selected products)

Illustrative per-product limits (not exhaustive; extractable entries for each product are present in chart):

Morphine sulfate oral solution 20 mg/5 mL: Column A initial 1 month ≤90 MME/day = 675 mL/month (22.5 mL/day); Column B initial 3 month ≤90 MME/day = 2025 mL/3 months; Column C post 1 month ≤200 MME/day = 1350 mL/month (45 mL/day); Column D post 3 month ≤200 MME/day = 4050 mL/3 months.per table

Chunk 54

Oxycodone tablets 5 mg: Column A initial 1 month ≤90 MME/day = 180 tablets/month (6/day, 45 MME/day); Column B initial 3 month ≤90 MME/day = 540 tablets/3 months; Column C post 1 month ≤200 MME/day = 270 tablets/month (9/day, 67.5 MME/day).per table

Chunks 60 and 64

Tramadol 25 mg: Column A initial 1 month ≤90 MME/day = 120 tablets/month (4/day, 20 MME/day); Column B initial 3 month ≤90 MME/day = 360 tablets/3 months; Column C post 1 month ≤200 MME/day = 180 tablets/month (6/day, 30 MME/day).

Quantity limits and duration-based coverage

Covered when prescription quantity and MME/day fall within the specified limits and indication matches approved DOA

General quantity criteria: Prescription must not exceed the MME/day and tablets/month (or mL/month) limits specified by product, dose, and column (initial 1 month, initial 3 month, post 1 month, post 3 month).see thresholds

Examples: Tramadol 25 mg initial 1 month = 120 tablets/month; Tramadol 100 mg post 1 month = 120 tablets/month

Duration of Approval by indication: Approval duration must match the indication: acute pain = 1 month; chronic pain = 6 months; cancer/sickle cell/terminal/hospice/palliative = 12 months.DOA per indication

From Duration of Approval section

Meperidine (Meperidine Hydrochloride tablets or oral solution) should not be used for treatment of chronic pain. The policy states meperidine must be reserved for patients who have not tolerated or are not expected to tolerate non‑opioid analgesics or opioid combination products and warns against extended use because of increased risk of toxicity (e.g., seizures) from accumulation of the metabolite normeperidine.

Claims for members with evidence within the prior 365 days of cancer or sickle cell disease (prescription fill), an ICD‑10 diagnosis for cancer, sickle cell disease, or palliative care on the prescription claim, an ICD‑10 cancer or palliative‑care diagnosis in the member profile, a history of an ICD‑10 code for sickle cell disease, or a hospice patient residence code will be paid under the prescription benefit and are routed outside the opioid quantity‑limit screening and acute‑duration rules described in this policy.

The policy’s acute pain duration limits (the 7‑day first‑fill constraint) and the product quantity/MME limits do not apply when the member has a prescription or diagnosis history in the past year indicating treatment for cancer or sickle cell disease, or when the claim includes ICD‑10 evidence of cancer, sickle cell disease, palliative care, or a hospice residence code. In such cases, the acute duration and quantity‑limit screen logic is bypassed.

For pentazocine/naloxone 50/0.5 mg the table explicitly indicates that Column B (Initial 3 Month) is marked as Does Not Apply. In other words, the initial 3‑month (Column B) initial‑use column is excluded for this product and should not be used when applying the columned quantity limits.

There are no other product‑level exclusions listed in the provided excerpts. Coverage constraints are applied through the numeric per‑product quantity and MME/day limits shown in the chart rather than by explicit additional product exclusions.

The policy notes that many common acute pain conditions (for example, post‑operative pain or acute musculoskeletal injuries) typically require no more than a few days of opioid therapy. Prescribing opioids for longer supplies for such acute conditions without meeting the policy criteria or obtaining prior authorization is not supported.

Requests that result in opioid use exceeding the specified MME/day or tablet/month limits (for example, exceeding the post‑tier limit of ≤ 200 MME/day) would be considered not medically necessary without appropriate justification or an approved prior authorization and therefore are at risk for denial.

Reference Codes and Key Thresholds

Document Referencemixed

2221-M

Reference/document identifier

Screening criteria referencesICD-10

No codes listed

Initial fill supply threshold

Initial first-fill supplyMaximum 7-day supply for a first opioid fill without prior authorization

Prior-fill triggerAn existing opioid fill of ≥8 days in the past 90 days shifts the claim to initial quantity-limit criteria (Column A/B)

PA for >7 days on first fillIf first fill is >7 days the claim will reject and a prior authorization may be submitted for additional quantity

Clinical lookback

Clinical lookback period365-day lookback for cancer, sickle cell disease, palliative care, or hospice indicators to route claim to prescription benefit

Evidence sources considered

Prior Authorization, Documentation, and Prescriber Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required when initial fills or subsequent requests exceed the program's acute 7‑day limit or the MME/quantity limits in the Opioid Analgesics IR Quantity Limits Chart. Claims for a patient's first opioid fill that are submitted for more than a 7‑day supply will reject with a message allowing only a 7‑day supply; a PA may be submitted for additional quantities. When a patient exceeds 7 days of opioid therapy for the first time in a 90‑day period, the claim will reject and a PA must be submitted for additional quantities. Requests exceeding the initial quantity limits (Column A/B corresponding to ≤ 90 MME/day) or the post limits (Column C/D corresponding to ≤ 200 MME/day) will require prior authorization review.

First-fill quantity reject: first opioid fill >7 days will reject; patient may receive a 7‑day supply unless a PA is approved.
PA required for quantities >7 days on first fill: a PA may be submitted when first-time opioid fill exceeds a 7‑day supply; PA criteria will be applied to the request.
Quantity/MME and duration-based prior authorization: PA required for quantities that exceed the MME/day or tablet/month limits per product and column (Initial Columns A/B or Post Columns C/D).
Quantity limit exceedance: requests beyond the stated MME/day thresholds (e.g., initial ≤90 MME/day vs post ≤200 MME/day) or tablet/month limits will be subject to PA and potential denial.
Implied denial risk if prescribing outside policy constraints: prescriptions exceeding the acute 7‑day limit or the charted MME/DOA limits may be denied if PA criteria are not met.

Clinical Background

Immediate‑release opioid analgesics are indicated for management of acute pain and, in some cases, chronic pain when the pain is severe enough to require an opioid and alternatives are inadequate. The policy emphasizes reserving opioids for patients who have not tolerated or not responded to non‑opioid options, limiting first fills to a maximum 7‑day supply in many circumstances, and applying initial and post thresholds measured in MME/day to determine allowable quantities.

Definitions and Terms

Limitations of Use (general opioid guidance)

Reserve opioidsReserve opioid use for patients who have not tolerated or not achieved adequate analgesia from non-opioid analgesics or opioid combination products

Avoid extended useDo not use opioids for extended periods unless pain remains severe and alternatives continue to be inadequate

Risk rationaleGuidance reflects risks of addiction, abuse, and misuse that can occur at any dosage or duration

Opioid product indications

Indication summarySpecific immediate‑release opioid products are indicated for management of pain severe enough to require an opioid when alternative treatments are inadequate

Formulations included

Initial Therapy — Product Limits and Requirements

Product-specific initial use limitations

Initial-use limitations common across products

Alternative therapy trial: Patient has not tolerated or is not expected to tolerate non‑opioid analgesics or opioid combination products.

Stated repeatedly in Limitations of Use

Adequate analgesia failure: Non‑opioid or alternative therapies have not provided adequate analgesia or are not expected to provide adequate analgesia.

Stated repeatedly in Limitations of Use

Avoid extended use: Opioid should not be used for an extended period unless pain remains severe and alternatives continue to be inadequate.

Stated across product Limitations of Use

Continuation Therapy and Duration of Approval

Continuation therapy durations

Duration of approval for ongoing therapy varies by indication.

Continuation durations: Chronic pain continuation approvals: up to 6 months; cancer/sickle cell/terminal/hospice/palliative: up to 12 months; acute pain: up to 1 month.time‑based DOA

From Duration of Approval section

Step Therapy and Prior Authorization Tables

Step	Requirement
1
Reserve opioid therapy for patients who have not tolerated or not achieved adequate analgesia from non‑opioid alternatives or opioid combination products (product‑specific Limitations of Use).

Step	Requirement
1
Prior authorization required to obtain quantities exceeding a 7‑day supply on a first opioid fill or to exceed the initial quantity limits (Column A/B limits corresponding to ≤90 MME/day); claims for first fills >7 days will reject and a PA may be submitted for additional quantities.

Product example	Column-specific note
Pentazocine/naloxone 50/0.5 mg
Column B (Initial 3 Month) does not apply for this product; other columns and limits apply as specified (see chart).

Observation	Implication
No step therapy sequences specified in the policy excerpt
Coverage is enforced via product‑ and dose‑specific quantity limits (Columns A–D) and MME/day thresholds rather than multi‑step prior‑therapy workflows.

Quantity Limits by Product and Strength

Opioid analgesics (IR/ER) — first-fill

First opioid fill without PAFirst opioid fill is limited to a 7-day supply without prior authorization; larger initial quantities require PA

Prior-fill adjustmentIf member has an ≥8‑day opioid fill in past 90 days, initial quantity limits per Column A/B apply instead of the 7‑day first‑fill restriction

Applies to IR and ER opioidsAcute 7‑day logic and initial quantity limits apply to immediate‑release and extended‑release opioids as described

Multiple IR opioid products — per-product limits

Per-product initial limitsMultiple IR opioid products have per-product initial limits corresponding to ≤90 MME/day (Column A per 25 days, Column B per 75 days)

Post limits

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOpioids IR - 7-Day Acute Pain Duration Limit with MME Limit and Post Limit

Policy CodePolicy 2221-M

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization when a first-time opioid fill exceeds a 7-day supply or when requesting quantities above initial MME limits.

SourceLink

On This Page

Patient with prior opioid use: If the patient has filled at least an 8‑day supply of an IR or ER opioid in the past 90 days, then the initial quantity‑limit criteria (Column A and Column B in the Opioid Analgesics IR Quantity Limits Chart) apply.>=8-day fill in past 90 days

Refer to quantity‑limit chart for numeric caps

Prescription claim drug fill, ICD-10 diagnosis on claim, ICD-10 in member profile, or hospice residence code within 365 days

Effect of positive screenIf present, requested drug is paid under the prescription benefit and is exempt from opioid quantity-limit screen logic

MME daily thresholds

Initial MME/day limit≤ 90 MME/day for initial (Column A/B) coverage tiers

Post/upper MME/day limit≤ 200 MME/day for post (Column C/D) coverage tiers, generally requiring prior authorization

Use in editsLimits are enforced as quantity‑vs‑time and daily dose edits across products (per 25 days for 1‑month, per 75 days for 3‑month)

Initial MME threshold

Initial MME threshold≤ 90 MME/day applies to Column A (Initial 1 month, per 25 days) and Column B (Initial 3 month, per 75 days)

Applies to both brand and genericInitial ≤90 MME/day limits apply regardless of brand or generic status

EnforcementInitial MME limits are implemented as daily dose edits and per-period quantity caps in the chart

Post MME threshold

Post MME threshold≤ 200 MME/day for post-treatment columns (Column C = Post 1 Month; Column D = Post 3 Month)

PA requirementCoverage for quantities corresponding to ≤200 MME/day is provided through prior authorization when approval criteria are met

Expressed as daily and per-period limitsPost limits are enforced both as MME/day edits and as tablet/mL per 25- or 75-day periods

MME/day thresholds (initial vs post)

Initial tiers MME/day≤ 90 MME/day for initial columns (Column A/B)

Post tiers MME/day≤ 200 MME/day for post columns (Column C/D)

Columns definedColumn A = Initial 1 Month (per 25 days); Column B = Initial 3 Month (per 75 days); Columns C/D = Post 1/3 Month respectively

Documentation Required

Documentation and Clinical Justification

Prescribers must document clinical justification and supporting evidence when submitting a PA or when prescribing near or above program limits. Required documentation includes relevant clinical notes/diagnoses and prescription history that demonstrate the need for quantities or MME above the initial limits. Chart documentation should support the requested dose, duration, and MME/day and align with the product-specific labeled dosing and the Duration of Approval (DOA) categories (acute, chronic, cancer/sickle cell/palliative/hospice).

Required documentation: clinical notes showing indication, prior treatment attempts or rationale for opioid use, and quantity/duration justification.
Required alignment with MME and DOA: documentation must demonstrate requests are consistent with the product-specific MME/day limits and the DOA (acute = 1 month; chronic = 6 months; cancer/sickle cell/palliative/hospice = 12 months).
Clinical guidance within product indications: opioids should be reserved for patients for whom alternative (non‑opioid) treatments are inadequate; documentation should reflect consideration of alternatives.

Note

Screening and Benefit Routing

Prior authorization determinations depend on diagnostic and prescription history screening. The program will screen member claims and profiles for cancer, sickle cell disease, palliative care, hospice residence codes, and recent opioid fills to determine whether the acute 7‑day rule or the initial quantity limits apply. If screen‑out criteria are met (cancer, sickle cell, palliative/hospice), the prescription is paid under that benefit; if screen‑out is not met, quantity limits and PA rules apply.

Clinical screen documentation: presence of a cancer/sickle cell/palliative diagnosis or hospice residence code on the claim or in the member profile within the defined lookback periods will exempt the patient from the acute 7‑day restriction and route payment under the appropriate benefit.
Diagnostic and prescription history screening: if no cancer/sickle cell/palliative/hospice indicators and no opioid ≥8‑day fill in the past 90 days, the initial quantity limits (Column A/B) apply; if an 8‑day (or greater) opioid fill is present in the past 90 days, initial quantity‑limit logic also applies.
Screen‑out not met — quantity limits apply: absent the exempting diagnoses or hospice code, the 7‑day acute limit, the initial quantity limits, and PA requirements will govern coverage.

Billing Rule

Products, Chart Exceptions, and Initial Limits

The Opioid Analgesics IR Quantity Limits Chart lists all affected products including both brand and generic names and all dosage forms/strengths unless otherwise noted (OTC excluded). Certain products have column‑specific restrictions or exceptions (for example, pentazocine/naloxone: Column B does not apply; use Column C/D rules as indicated). Prescribers should reference the chart for product‑specific per‑period and per‑day tablet/mL limits and the corresponding MME/day thresholds when requesting quantities beyond initial limits.

Product list includes brand and generic names and dosage forms: e.g., codeine sulfate (tablets), hydromorphone (oral solution, suppositories, tablets), levorphanol (tablets), meperidine (oral solution, tablets), morphine (solutions, suppositories, tablets), oxycodone (capsules, solutions, tablets), oxymorphone (tablets), pentazocine/naloxone (tablets), tapentadol (tablets), tramadol (solutions, tablets).
Column restrictions for specific products: follow the chart for product exceptions (e.g., pentazocine/naloxone — Column B Does Not Apply; use Column C/D).
Initial quantity‑limit trigger: if patient has an 8‑day (or greater) opioid fill in past 90 days, initial quantity limit criteria (Column A/B) apply as outlined in the chart.

Billing Rule

Operational/Dispensing Notes

Operational notes for prescribers and pharmacies: if an incoming first‑fill opioid claim exceeds a 7‑day supply it will reject and the pharmacy may dispense up to 7 days; submit a PA for additional days. If an initial prescription is within 7 days but the total requested quantity exceeds the product's initial MME/period limits, a PA is required for quantities above the charted initial limits. No formal step‑therapy sequence is specified in this program — limits and PA are primary controls.

Initial quantity then PA: initial coverage corresponds to ≤90 MME/day (Column A/B); PA review is required for additional quantities above these initial limits.
First‑fill >7 days rejects / First‑fill quantity reject: claims for first‑time opioid fills exceeding a 7‑day supply will reject with an instruction to limit to 7 days unless PA is approved.
Step therapy not specified: there is no explicit step therapy required — PA and quantity limits are applied per chart and clinical criteria.

Includes tablets, capsules, oral solutions, suppositories, and other immediate‑release formulations listed per product

Product examplesProducts listed include Oxaydo, oxycodone formulations, oxymorphone, pentazocine/naloxone, tramadol (Qdolo), morphine formulations, etc.

Limitations of use (per product)

Per-product limitation languageEach opioid product includes a limitation advising reserve use when non-opioid alternatives have not been tolerated or provided adequate analgesia

Common structureLimitations consistently state opioids should not be used long-term unless pain remains severe and alternatives remain inadequate

Applies across brands and genericsThis limitation-of-use language is repeated for multiple branded and generic products in the document

Acute pain

Definition of acute pain limitAcute pain: pain severe enough to require an opioid analgesic for a short course; first fills are limited to a maximum 7-day supply per fill

Operational effectIf a patient is opioid‑naïve (no ≥8‑day fill in past 90 days), incoming >7‑day fills will reject and allow a 7‑day supply unless PA is obtained

First exceedanceWhen patient exceeds 7 days of opioid therapy for the first time in a 90‑day period, prior authorization is required

Chronic pain

Chronic pain definitionChronic pain is generally defined as pain lasting greater than 3 months; authorization may be granted when monitoring and reassessment criteria are met

Monitoring requirementsPatient must be evaluated and monitored regularly for opioid use disorder; pain reassessed in first month after initial prescription or dose increase and every 3 months thereafter

Dose titration cautionReserve titration to higher doses only when lower doses are insufficient and benefits clearly outweigh substantial risks

Column A / B / C / D (summary)

Column A (Initial 1 Month)Per 25 days limit ≤90 MME/day (Initial 1 Month)

Column B (Initial 3 Month)Per 75 days limit ≤90 MME/day (Initial 3 Month)

Column C/D (Post)Post columns correspond to ≤200 MME/day (Post 1 Month / Post 3 Month)

MME/day

MME/day metricMorphine milligram equivalents per day (MME/day) is the metric used to set opioid prescribing limits

Thresholds appliedInitial tiers use ≤90 MME/day; Post tiers use ≤200 MME/day

Limits enforced as editsMME/day limits are enforced alongside per-period tablet/mL quantity caps in the chart

Product limitation-of-use requirements

Common limitation-of-use language across products

Reserve opioids: Reserve product for patients who have not tolerated or not achieved adequate analgesia from non‑opioid alternatives or opioid combination products; avoid extended use unless pain remains severe and alternatives remain inadequate.

Applies to each listed product

Initial therapy / first fill

Initial therapy limits for IR opioids:

Initial therapy limits: Potential first fills are limited to a maximum 7‑day supply per fill (up to 7 days of therapy in a 90‑day period). Initial quantity coverage corresponds to ≤90 MME/day per chart Columns A/B; quantities above require prior authorization.7 days; ≤90 MME/day

If patient lacks an 8‑day supply in prior 90 days, incoming >7‑day fill will reject; PA can be sought.

Initial therapy (Columns A/B)

Initial therapy quantity caps are expressed in Columns A (1 month, per 25 days) and B (3 months, per 75 days) with a ≤90 MME/day threshold.

Initial therapy Columns A/B: Dispensing within Column A or Column B limits (per product row) meets initial therapy quantity restrictions (≤90 MME/day).≤90 MME/day

See chart rows for product‑specific numeric caps

Initial therapy quantity limits

Initial quantity limits vary by product strength and column for 1‑month and 3‑month initial periods.

Initial 1 month limits: Examples: Tramadol 25 mg initial 1 month ≤90 MME/day = 120 tablets/month (4/day); Tramadol 75 mg initial 1 month ≤90 MME/day = 120 tablets/month (4/day).product‑specific tablet/month and tablets/day limits

See chart entries

Initial 3 month limits: Examples: Tramadol 25 mg initial 3 month ≤90 MME/day = 360 tablets/3 months; Tramadol 100 mg initial 3 month ≤90 MME/day = 270 tablets/3 months.product‑specific

See chart entries

Post limits for those products correspond to ≤200 MME/day (Column C/D) and generally require prior authorization

Examples includedChart lists specific tablet/month or mL/month caps per product and strength (see product rows for numeric caps)

Morphine sulfate oral solution 20 mg/5 mL

Morphine sulfate 20 mg/5 mL solution limitsColumn A: 675 mL/month (22.5 mL/day) for ≤90 MME/day; Column B: 2025 mL/3 months; Column C: 1350 mL/month for ≤200 MME/day; Column D: 4050 mL/3 months

Units and daysLimits expressed as mL/month with corresponding mL/day equivalents to meet MME thresholds

Post-tier PAHigher-volume post limits correspond to ≤200 MME/day and are subject to prior authorization when criteria apply

Oxycodone tablets/capsules (examples)

Oxycodone 5 mg tablets exampleColumn A (Initial 1 month ≤90 MME/day) = 180 tablets/month (6/day); Column C (Post 1 month ≤200 MME/day) = 270 tablets/month (9/day)

Per-period structureColumn A uses 25-day period for 1‑month fills; Column B uses 75‑day period for 3‑month fills; post columns likewise use per‑period limits

Applies to capsules and solutionsSimilar per-strength limits are listed for oxycodone capsules and oral solutions with MME/day equivalents

Tramadol (solutions and tablets) — examples

Tramadol overviewTramadol formulations have product-specific initial and post limits consistent with ≤90 MME/day initial tiers and ≤200 MME/day post tiers

Tramadol 25 mgInitial 1 month = 120 tablets/month (4/day) at ≤90 MME/day; Post 1 month = 180 tablets/month (6/day) at ≤200 MME/day

Tramadol solutionsExample: 5 mg/mL solution Column A = 1800 mL/month (60 mL/day, 60 MME/day) for ≤90 MME/day

Tramadol 25 mg

Tramadol 25 mg — initial limitsInitial 1 month: 120 tablets/month (4/day) at ≤90 MME/day; Initial 3 month: 360 tablets/3 months

Tramadol 25 mg — post limitsPost 1 month: 180 tablets/month (6/day) at ≤200 MME/day; Post 3 month: 540 tablets/3 months

MME/day equivalentsInitial and post tablet counts correspond to the stated MME/day thresholds in the chart

Tramadol 75 mg

Tramadol 75 mg — initial limitsInitial 1 month: 120 tablets/month (4/day) at ≤90 MME/day; Initial 3 month: 360 tablets/3 months

Tramadol 75 mg — post limitsPost 1 month: 150 tablets/month (5/day) at ≤200 MME/day; Post 3 month: 450 tablets/3 months

Per-day tablet countsTablet/day limits shown in chart correspond to MME/day calculations for each strength

Tramadol 100 mg

Tramadol 100 mg — initial limitsInitial 1 month: 90 tablets/month (3/day) at ≤90 MME/day; Initial 3 month: 270 tablets/3 months

Tramadol 100 mg — post limitsPost 1 month: 120 tablets/month (4/day) at ≤200 MME/day; Post 3 month: 360 tablets/3 months

Strength-specific MMEHigher-strength tramadol has correspondingly lower tablet/day caps to maintain the MME/day thresholds