Opioid Analgesic/Opioid Combination Products
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1 Opioid Analgesic/Opioid Combination Products Override(s) Quantity Limit Approval Duration 1 year Generic Name Brand Name Quantity Limit 320.5mg/30mg/16mg 356.4mg/30mg/16mg 325mg/30mg/16mg Trezix (new formulation) Trezix (old formulation) 10 capsules per 11 capsules per 10 tablets per ASA/Caf/Dihydrocodeine Synalgos-DC 11 capsules per 356mg/30mg/16mg APAP/codeine 300mg/15mg Tylenol with Codeine 13 tablets per APAP/codeine 300mg/30mg Tylenol with Codeine 12 tablets per APAP/codeine 300mg/60mg Tylenol with Codeine 6 tablets per APAP/codeine Suspension or Elixir Capital with Codeine 90 per 120mg-12mg/5 Buprenorphine HCl ampule 0.3 Buprenex 3 per Buprenorphine HCl syringe/vial per Butalbital/APAP/Caffeine/Codeine Fioricet with Codeine 6 capsules per 50/300/40/30mg Butalbital/APAP/Caffeine/Codeine 6 capsules per 50/325/40/30mg Butalbital/ASA/Caffeine/Codeine Ascomp with Codeine, Fiorinal 6 capsules per 50/325/40/30mg with Codeine Butorphanol 1 injection Stadol 8 per Butorphanol 2 injection Stadol 4 per Codeine sulfate 15 mg, 30 mg 12 tablets per Codeine sulfate 60 mg 6 tablets per Hydrocodone/APAP 7.5- Hycet 325mg/15 Hydrocodone/APAP mg/15mg Zamicet PAGE 1 of 5 09/07/2017
2 Hydrocodone/APAP mg/15 Lortab, ZolvitSolution 67.5 per Hydrocodone/APAP 10/300 mg Vicodin HP (new formulation), 13 tablets per Xodol Hydrocodone/APAP 10/500 mg, Lortab (old formulation) 2.5/500 mg, 7.5/500 mg Hydrocodone/APAP 10/660 mg Vicodin HP (old formulation) 6 tablets per Hydrocodone/APAP 10/750 mg Maxidone 5 tablets per Hydrocodone/APAP mg/5 Hydrocodone/APAP mg/5 Hydrocodone/APAP 5-217mg/10 Hydrocodone/APAP 5/300 mg, Vicodin (new formulation), Xodol 13 tablets per 7.5mg/300 mg, 10/300 mg Hydrocodone/APAP 2.5/325mg, Anexsia, Norco, Lorcet (new 12 tablets per 5/325 mg, 7.5/325 mg, 10/325 mg formulation), Lorcet Plus (new formulation), Lorcet HD (new formulation), Verdocet Hydrocodone/APAP mg/10 Hydrocodone/APAP 5/400 mg, Zydone 10 tablets per 7.5/400 mg, 10/400 mg Hydrocodone/APAP 5/500 mg tablets Co-Gesic Lortab (old formulation), Hydrocodone/APAP 7.5/500 Lortab Hydrocodone/APAP 7.5/650 mg, Anexsia (old formulation), Lorcet 6 tablets per 10/650 mg (old formulation), Lorcet Plus (oldformulation) Hydrocodone/APAP 7.5/750 mg Vicodin ES (old formulation) 5 tablets per Hydrocodone/Ibuprofen 2.5/200 mg, Ibudone, Reprexain, Vicoprofen, 5 tablets per 5/200 mg, 7.5/200 mg, 10/200 mg Xylone Hydromorphone 2 mg, 4 mg Dilaudid 12 tablets per Hydromorphone 8 mg Dilaudid 6 tablets per Hydromorphone suppository 3 mg Dilaudid 4 suppositories per Hydromorphone oral liquid 1 Dilaudid 24 per Hydromorphone injection 10 Dilaudid-HP 1 injection per 30 PAGE 2 of 5 09/07/2017
3 Hydromorphone injection 1, Dilaudid 2 Hydromorphone injection 4 Dilaudid 2 per Meperidine 100 mg Demerol 6 tablets per Meperidine 50 mg Demerol 12 tablets per Meperidine injection 50 Demerol 60 per Meperidine injection 10, 25 Demerol, 75, 100, 100 mg/2 (pf) injection solution 0.5 Astramorph-PF, 1 injection 0.5, 1 Duramorph sulfate injection 10mg/0.7 sulfate injection 2, 4, 5, 8, 10 sulfate injection 15, 25 sulfate solution 10mg/5 4 per 6 injections/pens per 4 per sulfate injection 150mg/30 1 vial (30 ) per sulfate rectal suppositories 5 mg, 10 mg, 20 mg, 6 suppositories per 30 mg Sulfate Solution 45 per 20mg/5 Sulfate 20 Oral 9 per Syringe solution 20 Roxanol 9 per Nalbuphene injection 10, Nubain 2 per 20 Oxycodone 5 mg Roxicodone 12 tablets per Oxycodone 5 mg OxylR 5 mg 12 capsules per Oxycodone 10mg 12 tablets per Oxycodone 15 mg Roxicodone 6 tablets per Oxycodone 20mg 6 tablets per Oxycodone 30 mg Roxicodone 6 tablets per PAGE 3 of 5 09/07/2017
4 Oxycodone 5mg, 7.5mg Oxaydo 5 mg, 7.5 mg 12 tablets per Oxycodone concentrate 20 Oxycodone solution 5mg/5 60 per Oxycodone oral syringe 10mg/0.5 Oxycodone 7.5/500 mg Percocet Oxycodone/APAP Magnacet 10 tablets per Oxycodone/APAP 10/500 mg tablet Xolox Oxycodone/APAP 10/650 mg Percocet 6 tablets per Oxycodone/APAP 2.5/325 mg, Endocet, Percocet, Roxicet 12 tablets per 5/325 mg, mg, 10/325 mg Oxycodone/APAP 5/300 mg, Primlev 13 tablets per 7.5/300 mg, 10/300 mg Oxycodone/APAP 5/500 mg Tylox capsule Oxycodone/APAP 5/500 mg tablet Roxicet Oxycodone/APAP 5-325mg/5 Roxicet Solution 60 per solution Oxycodone/APAP 7.5/325 mg Xartemis XR 4 tablets per extended-release Oxycodone/ASA 5/325 mg Endodan, Percodan 12 tablets per (4.8355/325mg) Oxycodone/IBU Combunox 4 tabs/ AND 28 tabs/fill Pentazocine Talwin per Pentazocine/naloxone 50/0.5mg 12 tablets per Tapentadol HCl 50mg Nucynta 362 tablets per 30 Tapentadol HCl 75 mg Nucynta 242 tablets per 30 Tramadol Ultram Tramadol/APAP 37.5/325mg Ultracet PAGE 4 of 5 09/07/2017
5 APPROVAL CRITERIA For Opioid/ Opioid Analgesic Combination agents that have a maximum FDA- approved dosing, quantity limits are assigned based on FDA- approved maximum adult daily dose. - Acetaminophen: 4000mg per - Aspirin: 4000mg per - Codeine: 360mg per - Nucynta (tapentadol) immediate-release: 700 mg per on 1, 600mg per thereafter - Oxycodone/Ibuprofen: 4 tablets per AND 28 tablets /fill - Talwin injection (pentazocine): 360 mg per - Tramadol: 400 mg per There are no criteria to override the limit for agents with an FDA approved daily maximum dose. For approval of increased quantities of select single agent narcotic analgesics without FDA-approved maximum daily dose, the following criteria must be met: I. Requests for increased quantity can be approved for the diagnosis of cancer related pain. Note: It may be possible in some instances to use a higher strength of the requested medication and take fewer tablets/capsules to achieve the same total daily dosage requested. State name Date effective State Specific Mandates Mandate details (including specific bill if applicable) Key References: Clinical Pharmacology [database online]. Tampa, : Gold Standard, Inc.: URL: Updated periodically. DailyMed. Package inserts. U.S. National Library of Medicine, National Institutes of Health website. Accessed January 30, DrugPoints System (electronic version). Truven Health Analytics, Greenwood Village, CO. Updated periodically. Lexi-Comp ONLINE with AHFS, Hudson, Ohio: Lexi-Comp, Inc.; 2017; Updated periodically. PAGE 5 of 5 09/07/2017
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