Opioids, Short-Acting
PDL Reference Documents
Drug Use Review Documents
Newsletters
- November 2019 - Update on Recent Guidance and Safety Alerts for Opioid Use in Non-cancer Pain
- July 2017 - Tramadol and Codeine Use In Pediatrics: A Review of Recent FDA Safety Alerts
- December 2016 - Guideline and Policy Updates for Use of Opioids for Non-Cancer Pain and Opioid Use Disorder
- February 2016 - 2015 in Review: Relevant Safety Updates and Ongoing Safety Concerns
- March 2015 - Combating the Opioid Epidemic: Are Abuse-deterrent Formulations the Answer?
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 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 | |
oxycodone HCl/acetaminophen | OXYCODONE-ACETAMINOPHEN | TABLET | Y | Quantity Limit | |
oxycodone HCl/acetaminophen | PERCOCET | TABLET | Y | Quantity Limit | |
tramadol HCl | TRAMADOL HCL | TABLET | Y | Quantity Limit | |
acetaminophen/caff/dihydrocod | ACETAMIN-CAFF-DIHYDROCODEINE | CAPSULE | N | Quantity Limit | |
acetaminophen/caff/dihydrocod | ACETAMIN-CAFF-DIHYDROCODEINE | TABLET | 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 | BUTALBITAL COMPOUND-CODEINE | CAPSULE | N | PA Document | |
codeine/butalbital/ASA/caffein | ASCOMP WITH CODEINE | CAPSULE | N | PA Document | |
codeine/butalbital/ASA/caffein | ASA-BUTALB-CAFFEINE-CODEINE | CAPSULE | N | PA Document | |
fentanyl citrate | ACTIQ | LOZENGE HD | N | Quantity Limit | |
fentanyl citrate | FENTANYL CITRATE | 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 | HYDROMORPHONE HCL | LIQUID | N | Quantity Limit | |
hydromorphone HCl | DILAUDID | 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 | OXYCODONE-ACETAMINOPHEN | SOLUTION | N | Quantity Limit | |
oxycodone HCl/acetaminophen | PROLATE | SOLUTION | N | Quantity Limit | |
oxycodone HCl/acetaminophen | ROXICET | TABLET | N | Quantity Limit | |
oxycodone HCl/acetaminophen | PROLATE | 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 |