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 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
ACETAMINOPHEN WITH CODEINE CAPITAL W-CODEINE ORAL SUSP Y PA Document  
ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN-CODEINE SOLUTION Y PA Document  
ACETAMINOPHEN WITH CODEINE TYLENOL-CODEINE NO.3 TABLET Y PA Document  
ACETAMINOPHEN WITH CODEINE TYLENOL-CODEINE NO.4 TABLET Y PA Document  
ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN-CODEINE TABLET Y PA Document  
BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE SPRAY Y Quantity Limit  
CODEINE SULFATE CODEINE SULFATE TABLET Y PA Document  
HYDROCODONE/ACETAMINOPHEN LORTAB SOLUTION Y Quantity Limit  
HYDROCODONE/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN SOLUTION Y Quantity Limit  
HYDROCODONE/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN TABLET Y Quantity Limit  
HYDROCODONE/ACETAMINOPHEN LORCET TABLET Y Quantity Limit  
HYDROCODONE/ACETAMINOPHEN LORCET HD TABLET Y Quantity Limit  
HYDROCODONE/ACETAMINOPHEN LORCET PLUS TABLET Y Quantity Limit  
HYDROCODONE/ACETAMINOPHEN NORCO 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  
OXYCODONE HCL OXYCODONE HCL SOLUTION Y Quantity Limit  
OXYCODONE HCL OXYCODONE HCL TABLET Y Quantity Limit  
OXYCODONE HCL ROXICODONE TABLET Y Quantity Limit  
OXYCODONE HCL/ACETAMINOPHEN PERCOCET TABLET Y Quantity Limit  
OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN TABLET Y Quantity Limit  
OXYCODONE HCL/ACETAMINOPHEN ENDOCET TABLET Y Quantity Limit  
TRAMADOL HCL ULTRAM TABLET Y Quantity Limit  
TRAMADOL HCL TRAMADOL HCL TABLET Y Quantity Limit  
ASPIRIN/CAFFEIN/DIHYDROCODEINE SYNALGOS-DC CAPSULE N Quantity Limit  
BUTALBIT/ACETAMIN/CAFF/CODEINE BUTALB-ACETAMINOPH-CAFF-CODEIN CAPSULE N PA Document  
BUTALBIT/ACETAMIN/CAFF/CODEINE BUTALB-CAFF-ACETAMINOPH-CODEIN 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  
CODEINE/BUTALBITAL/ASA/CAFFEIN FIORINAL WITH CODEINE #3 CAPSULE N PA Document  
FENTANYL SUBSYS SPRAY N Quantity Limit  
FENTANYL CITRATE FENTANYL CITRATE LOZENGE HD N Quantity Limit  
FENTANYL CITRATE ACTIQ LOZENGE HD N Quantity Limit  
FENTANYL CITRATE LAZANDA SPRAY/PUMP N Quantity Limit  
FENTANYL CITRATE ABSTRAL TAB SUBL N Quantity Limit  
FENTANYL CITRATE FENTORA TABLET EFF N Quantity Limit  
HYDROCODONE/ACETAMINOPHEN ZAMICET SOLUTION N Quantity Limit  
HYDROCODONE/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN TABLET N Quantity Limit  
HYDROCODONE/ACETAMINOPHEN VICODIN TABLET N Quantity Limit  
HYDROCODONE/ACETAMINOPHEN XODOL 5-300 TABLET N Quantity Limit  
HYDROCODONE/ACETAMINOPHEN XODOL 10-300 TABLET N Quantity Limit  
HYDROCODONE/ACETAMINOPHEN VICODIN HP TABLET N Quantity Limit  
HYDROCODONE/ACETAMINOPHEN XODOL 7.5-300 TABLET N Quantity Limit  
HYDROCODONE/ACETAMINOPHEN VICODIN ES TABLET N Quantity Limit  
HYDROCODONE/IBUPROFEN IBUDONE TABLET N Quantity Limit  
HYDROCODONE/IBUPROFEN XYLON 10 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  
IBUPROFEN/OXYCODONE HCL OXYCODONE HCL-IBUPROFEN TABLET N Quantity Limit  
MEPERIDINE HCL MEPERIDINE HCL SOLUTION N Quantity Limit  
MEPERIDINE HCL DEMEROL TABLET N Quantity Limit  
MEPERIDINE HCL MEPERIDINE HCL TABLET N Quantity Limit  
MORPHINE SULFATE MORPHINE SULFATE SYRINGE N Quantity Limit  
MORPHINE SULFATE ARYMO ER TAB PO ER N Quantity Limit  
OXYCODONE HCL OXYCODONE HCL CAPSULE N Quantity Limit  
OXYCODONE HCL OXYCODONE HCL ORAL CONC N Quantity Limit  
OXYCODONE HCL OXYCODONE HCL SYRINGE N Quantity Limit  
OXYCODONE HCL OXAYDO TABLET ORL N Quantity Limit  
OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN SOLUTION N Quantity Limit  
OXYCODONE HCL/ACETAMINOPHEN PRIMLEV TABLET N Quantity Limit  
OXYCODONE HCL/ASPIRIN OXYCODONE HCL-ASPIRIN TABLET N Quantity Limit  
OXYMORPHONE HCL OXYMORPHONE HCL TABLET N Quantity Limit  
OXYMORPHONE HCL OPANA TABLET N Quantity Limit  
PENTAZOCINE HCL/NALOXONE HCL PENTAZOCINE-NALOXONE HCL TABLET N Quantity Limit  
TAPENTADOL HCL NUCYNTA TABLET N Quantity Limit  
TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL-ACETAMINOPHEN TABLET N Quantity Limit  
TRAMADOL HCL/ACETAMINOPHEN ULTRACET TABLET N Quantity Limit