Opioids, Short-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.
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
acetaminophen with codeine ACETAMINOPHEN W/CODEINE ELIXIR Y PA Document  
acetaminophen with codeine ACETAMINOPHEN-CODEINE SOLUTION Y PA Document  
acetaminophen with codeine ACETAMINOPHEN-CODEINE TABLET Y PA Document  
acetaminophen with codeine ACETAMINOPHEN W/CODEINE TABLET Y PA Document  
butorphanol tartrate BUTORPHANOL TARTRATE SPRAY Y Quantity Limit  
codeine sulfate CODEINE SULFATE TABLET Y PA Document  
hydrocodone/acetaminophen HYDROCODONE-ACETAMINOPHEN SOLUTION Y Quantity Limit  
hydrocodone/acetaminophen HYDROCODONE-ACETAMINOPHEN TABLET Y Quantity Limit  
hydrocodone/acetaminophen HYDROCODONE W/ACETAMINOPHEN TABLET Y Quantity Limit  
hydrocodone/acetaminophen HYDROCODONE/ACETAMINOPHEN TABLET Y Quantity Limit  
hydromorphone HCl HYDROMORPHONE HCL SUPP.RECT Y Quantity Limit  
hydromorphone HCl DILAUDID TABLET Y Quantity Limit  
hydromorphone HCl HYDROMORPHONE HCL TABLET Y Quantity Limit  
morphine sulfate MORPHINE SULFATE SOLUTION Y Quantity Limit  
morphine sulfate MORPHINE SULFATE SUPP.RECT Y Quantity Limit  
morphine sulfate MORPHINE SULFATE TABLET Y Quantity Limit  
opium/belladonna alkaloids BELLADONNA-OPIUM SUPP.RECT Y Quantity Limit  
opium/belladonna alkaloids BELLADONNA & OPIUM SUPP.RECT Y Quantity Limit  
oxycodone HCl OXYCODONE HCL SOLUTION Y Quantity Limit  
oxycodone HCl ROXICODONE TABLET Y Quantity Limit  
oxycodone HCl OXYCODONE HCL TABLET Y Quantity Limit  
oxycodone HCl/acetaminophen OXYCODONE W/ACETAMINOPHEN CAPSULE Y Quantity Limit  
oxycodone HCl/acetaminophen OXYCODONE-ACETAMINOPHEN TABLET Y Quantity Limit  
oxycodone HCl/acetaminophen PERCOCET TABLET Y Quantity Limit  
oxycodone HCl/acetaminophen OXYCODONE W/ACETAMINOPHEN TABLET Y Quantity Limit  
oxycodone HCl/acetaminophen OXYCODONE HCL-ACETAMINOPHEN TABLET Y Quantity Limit  
oxycodone HCl/acetaminophen NALOCET TABLET Y Quantity Limit  
oxycodone HCl/acetaminophen ENDOCET TABLET Y Quantity Limit  
tramadol HCl TRAMADOL HCL TABLET Y Quantity Limit  
acetaminophen/caff/dihydrocod ACETAMIN-CAFF-DIHYDROCODEINE CAPSULE N Quantity Limit  
aspirin/codeine phosphate ASPIRIN W/CODEINE TABLET N PA Document  
butalbit/acetamin/caff/codeine FIORICET WITH CODEINE CAPSULE N PA Document  
butalbit/acetamin/caff/codeine BUTALB-ACETAMINOPH-CAFF-CODEIN CAPSULE N PA Document  
codeine/butalbital/ASA/caffein ASA-BUTALB-CAFFEINE-CODEINE CAPSULE N PA Document  
codeine/butalbital/ASA/caffein ASCOMP WITH CODEINE CAPSULE N PA Document  
codeine/butalbital/ASA/caffein BUTALBITAL COMPOUND-CODEINE CAPSULE N PA Document  
fentanyl citrate FENTANYL CITRATE LOZENGE HD N Quantity Limit  
fentanyl citrate ACTIQ LOZENGE HD N Quantity Limit  
fentanyl citrate FENTORA TABLET EFF N Quantity Limit  
fentanyl citrate FENTANYL CITRATE TABLET EFF N Quantity Limit  
hydrocodone/acetaminophen HYDROCODONE W/ACETAMINOPHEN ELIXIR N Quantity Limit  
hydrocodone/acetaminophen VERDROCET TABLET N Quantity Limit  
hydrocodone/acetaminophen HYDROCODONE-ACETAMINOPHEN TABLET N Quantity Limit  
hydrocodone/ibuprofen HYDROCODONE-IBUPROFEN TABLET N Quantity Limit  
hydromorphone HCl DILAUDID LIQUID N Quantity Limit  
hydromorphone HCl HYDROMORPHONE HCL LIQUID N Quantity Limit  
meperidine HCl MEPERIDINE HCL SOLUTION N Quantity Limit  
meperidine HCl MEPERIDINE HCL TABLET N Quantity Limit  
morphine sulfate MORPHINE SULFATE SYRINGE N Quantity Limit  
oxycodone HCl OXYCODONE HCL CAPSULE N Quantity Limit  
oxycodone HCl OXYCODONE HCL ORAL CONC N Quantity Limit  
oxycodone HCl ROXYBOND TABLET ORL N Quantity Limit  
oxycodone HCl/acetaminophen PROLATE SOLUTION N Quantity Limit  
oxycodone HCl/acetaminophen OXYCODONE-ACETAMINOPHEN SOLUTION N Quantity Limit  
oxycodone HCl/acetaminophen PROLATE TABLET N Quantity Limit  
oxycodone HCl/acetaminophen ROXICET TABLET N Quantity Limit  
oxymorphone HCl NUMORPHAN SUPP.RECT N Quantity Limit  
oxymorphone HCl OXYMORPHONE HCL TABLET N Quantity Limit  
pentazocine HCl/naloxone HCl PENTAZOCINE-NALOXONE HCL TABLET N Quantity Limit  
propoxyphene nap/acetaminophen PROPOXYPHENE NAPSYLATE W/APAP TABLET N Quantity Limit  
sufentanil citrate DSUVIA TAB IN APP N Quantity Limit  
tapentadol HCl NUCYNTA TABLET N Quantity Limit  
tramadol HCl TRAMADOL HCL SOLUTION N Quantity Limit  
tramadol HCl TRAMADOL HCL TABLET N Quantity Limit  
tramadol HCl/acetaminophen TRAMADOL HCL-ACETAMINOPHEN TABLET N Quantity Limit  
tramadol HCl/celecoxib SEGLENTIS TABLET N Quantity Limit