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 ACETAMINOPHEN W/CODEINE ELIXIR Y PA Document  
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.4 TABLET Y PA Document  
acetaminophen with codeine TYLENOL-CODEINE NO.3 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 CO-GESIC TABLET Y Quantity Limit  
hydrocodone/acetaminophen LORCET PLUS TABLET 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 NORCO TABLET Y Quantity Limit  
hydrocodone/acetaminophen LORTAB TABLET Y Quantity Limit  
hydromorphone HCl HYDROMORPHONE HCL SUPP.RECT Y Quantity Limit  
hydromorphone HCl HYDROMORPHONE HCL TABLET Y Quantity Limit  
hydromorphone HCl DILAUDID 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 ROXICODONE TABLET Y Quantity Limit  
oxycodone HCl OXYCODONE HCL 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  
acetaminophen with codeine ACETAMINOPHEN-CODEINE SOLUTION N PA Document  
butalbit/acetamin/caff/codeine FIORICET WITH CODEINE CAPSULE N PA Document  
butalbit/acetamin/caff/codeine BUTALB-CAFF-ACETAMINOPH-CODEIN CAPSULE N PA Document  
butalbit/acetamin/caff/codeine BUTALB-ACETAMINOPH-CAFF-CODEIN CAPSULE N PA Document  
codeine/butalbital/ASA/caffein FIORINAL WITH CODEINE #3 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 SUBSYS SPRAY N Quantity Limit  
fentanyl citrate ACTIQ LOZENGE HD N Quantity Limit  
fentanyl citrate FENTANYL CITRATE 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 VICODIN HP TABLET N Quantity Limit  
hydrocodone/acetaminophen VICODIN ES TABLET N Quantity Limit  
hydrocodone/ibuprofen HYDROCODONE-IBUPROFEN TABLET N Quantity Limit  
hydrocodone/ibuprofen REPREXAIN TABLET N Quantity Limit  
hydrocodone/ibuprofen XYLON 10 TABLET N Quantity Limit  
hydrocodone/ibuprofen IBUDONE 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  
propoxyphene HCl PROPOXYPHENE HCL CAPSULE N Quantity Limit  
propoxyphene HCl/acetaminophen PROPOXYPHENE HCL-ACETAMINOPHEN TABLET N Quantity Limit  
tapentadol HCl NUCYNTA TABLET N Quantity Limit  
tramadol HCl/acetaminophen ULTRACET TABLET N Quantity Limit  
tramadol HCl/acetaminophen TRAMADOL HCL-ACETAMINOPHEN TABLET N Quantity Limit