Opioids, Long-Acting

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
fentanyl FENTANYL PATCH TD72 Y Quantity Limit  
fentanyl DURAGESIC PATCH TD72 Y Quantity Limit  
morphine sulfate MS CONTIN TABLET ER Y Quantity Limit  
morphine sulfate MORPHINE SULFATE ER TABLET ER Y Quantity Limit  
buprenorphine BUTRANS PATCH TDWK N Quantity Limit  
buprenorphine BUPRENORPHINE PATCH TDWK N Quantity Limit  
buprenorphine HCl BELBUCA FILM N Quantity Limit  
fentanyl FENTANYL PATCH TD72 N Quantity Limit  
hydrocodone bitartrate ZOHYDRO ER CAP ER 12H N Quantity Limit  
hydrocodone bitartrate HYSINGLA ER TAB ER 24H N Quantity Limit  
hydromorphone HCl EXALGO TAB ER 24H N Quantity Limit  
hydromorphone HCl HYDROMORPHONE ER TAB ER 24H N Quantity Limit  
levorphanol tartrate LEVORPHANOL TARTRATE TABLET N Quantity Limit  
methadone HCl METHADONE HCL ORAL CONC N Quantity Limit  
methadone HCl METHADONE INTENSOL ORAL CONC N Quantity Limit  
methadone HCl METHADOSE ORAL CONC N Quantity Limit  
methadone HCl METHADONE HCL SOLUTION N Quantity Limit  
methadone HCl METHADONE HCL TABLET N Quantity Limit  
methadone HCl DOLOPHINE HCL TABLET N Quantity Limit  
methadone HCl DISKETS TABLET SOL N Quantity Limit  
methadone HCl METHADONE HCL TABLET SOL N Quantity Limit  
methadone HCl METHADOSE TABLET SOL N Quantity Limit  
morphine sulfate KADIAN CAP ER PEL N Quantity Limit  
morphine sulfate MORPHINE SULFATE ER CAP ER PEL N Quantity Limit  
morphine sulfate MORPHINE SULFATE ER CPMP 24HR N Quantity Limit  
morphine sulfate MORPHABOND ER TAB ER 12H N Quantity Limit  
morphine sulfate/naltrexone EMBEDA CAP ER PO N Quantity Limit  
oxycodone HCl OXYCODONE HCL ER TAB ER 12H N Quantity Limit  
oxycodone HCl OXYCONTIN TAB ER 12H N Quantity Limit  
oxycodone myristate XTAMPZA ER CAP SPR 12 N Quantity Limit  
oxymorphone HCl OPANA ER TAB ER 12H N Quantity Limit  
oxymorphone HCl OXYMORPHONE HCL ER TAB ER 12H N Quantity Limit  
tapentadol HCl NUCYNTA ER TAB ER 12H N Quantity Limit  
tramadol HCl CONZIP CPBP 17-83 N Quantity Limit  
tramadol HCl TRAMADOL HCL ER CPBP 17-83 N Quantity Limit  
tramadol HCl TRAMADOL HCL ER CPBP 25-75 N Quantity Limit  
tramadol HCl CONZIP CPBP 25-75 N Quantity Limit  
tramadol HCl TRAMADOL HCL ER TAB ER 24H N Quantity Limit  
tramadol HCl TRAMADOL HCL ER TBMP 24HR N Quantity Limit