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 DURAGESIC PATCH TD72 Y Quantity Limit  
FENTANYL FENTANYL PATCH TD72 Y Quantity Limit  
MORPHINE SULFATE MORPHINE SULFATE ER TABLET ER Y Quantity Limit  
MORPHINE SULFATE MS CONTIN TABLET ER Y Quantity Limit  
BUPRENORPHINE BUPRENORPHINE PATCH TDWK N Quantity Limit  
BUPRENORPHINE BUTRANS 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 HYDROMORPHONE ER TAB ER 24H N Quantity Limit  
HYDROMORPHONE HCL EXALGO 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 METHADOSE ORAL CONC N Quantity Limit  
METHADONE HCL METHADONE INTENSOL 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 METHADOSE TABLET SOL N Quantity Limit  
METHADONE HCL DISKETS TABLET SOL N Quantity Limit  
METHADONE HCL METHADONE HCL TABLET SOL N Quantity Limit  
MORPHINE SULFATE MORPHINE SULFATE ER CAP ER PEL N Quantity Limit  
MORPHINE SULFATE KADIAN CAP ER PEL N Quantity Limit  
MORPHINE SULFATE MORPHINE SULFATE ER CPMP 24HR 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 OXYMORPHONE HCL 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 CONZIP CPBP 25-75 N Quantity Limit  
TRAMADOL HCL TRAMADOL HCL ER 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