Opioids, Long-Acting

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PDL Reference Documents

Drug Use Review Documents

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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.
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 PA Document  
morphine sulfate MORPHINE SULFATE ER TABLET ER Y PA Document  
morphine sulfate MS CONTIN TABLET ER Y PA Document  
buprenorphine BUPRENORPHINE PATCH TDWK N PA Document  
buprenorphine BUTRANS PATCH TDWK N PA Document  
buprenorphine HCl BELBUCA FILM N PA Document  
buprenorphine HCl BUPRENORPHINE HCL FILM N PA Document  
fentanyl FENTANYL PATCH TD72 N PA Document  
hydrocodone bitartrate HYDROCODONE BITARTRATE ER CAP ER 12H N PA Document  
hydrocodone bitartrate HYDROCODONE BITARTRATE ER TAB ER 24H N PA Document  
hydrocodone bitartrate HYSINGLA ER TAB ER 24H N PA Document  
hydromorphone HCl HYDROMORPHONE ER TAB ER 24H N PA Document  
levorphanol tartrate LEVORPHANOL TARTRATE TABLET N PA Document  
methadone HCl METHADOSE ORAL CONC N PA Document  
methadone HCl METHADONE HCL ORAL CONC N PA Document  
methadone HCl METHADONE INTENSOL ORAL CONC N PA Document  
methadone HCl METHADONE HCL SOLUTION N PA Document  
methadone HCl METHADONE HCL TABLET N PA Document  
methadone HCl METHADOSE TABLET SOL N PA Document  
methadone HCl METHADONE HCL TABLET SOL N PA Document  
morphine sulfate MORPHINE SULFATE ER CAP ER PEL N PA Document  
morphine sulfate MORPHINE SULFATE ER CPMP 24HR N PA Document  
oxycodone HCl OXYCODONE HCL ER TAB ER 12H N PA Document  
oxycodone HCl OXYCONTIN TAB ER 12H N PA Document  
oxycodone myristate XTAMPZA ER CAP SPR 12 N PA Document  
oxymorphone HCl OXYMORPHONE HCL ER TAB ER 12H N PA Document  
tapentadol HCl NUCYNTA ER TAB ER 12H N PA Document  
tramadol HCl CONZIP CPBP 17-83 N PA Document  
tramadol HCl TRAMADOL HCL ER CPBP 17-83 N PA Document  
tramadol HCl CONZIP CPBP 25-75 N PA Document  
tramadol HCl TRAMADOL HCL ER CPBP 25-75 N PA Document  
tramadol HCl TRAMADOL HCL ER TAB ER 24H N PA Document  
tramadol HCl TRAMADOL HCL ER TBMP 24HR N PA Document  
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