Comment
Author: Admin | 2025-04-28
33 Prolate prescribing information. Forte Bio-Pharma LLC. September 2021. 34 Qdolo prescribing information. Athena Bioscience, LLC. September 2021. 35 Roxicodone prescribing information. Specgx LLC. January 2023. 36 Seglentis prescribing information. Kowa Pharmaceuticals America, Inc. October 2021. 37 Trezix prescribing information. Wraser Pharms LLC. February 2021. 38 Tylenol with codeine prescribing information. A-S Medication Solutions. April 2019. 39 Ultracet prescribing information. Jassen Pharma. February 2023. 40 Ultram prescribing information Janssen Pharms. February 2023. 41 Roxybond prescribing information. Protega Pharms. March 2021. OBJECTIVEThe intent of the Opioids IR quantity limit is to encourage FDA approved dosing regimen. Requests for larger quantities will be approved upon review. The program will also check for appropriate age for requests for products containing tramadol, dihydrocodeine, and codeine. Requests for these agents will be limited to patients 12 years of age and older, and patients 12 years to 18 years will be restricted from use for post-operative pain management following a tonsillectomy and/or adenoidectomy.POLICY AGENT SUMMARY QUANTITY LIMIT Target Brand Agent Name(s) Target Generic Agent Name(s) Strength QL Amount Dose Form Day Supply Duration Addtl QL Info Allowed Exceptions Targeted NDCs When Exclusions Exist Acetaminophen w/ Codeine Soln 120-12 MG/5ML 120-12 MG/5ML 2700 mLs 30 DAYS Acetaminophen w/ Codeine Tab 300-15 MG 300-15 MG 360 Tablets 30 DAYS Acetaminophen w/ Codeine Tab 300-30 MG 300-30 MG 360 Tablets 30 DAYS Acetaminophen w/ Codeine Tab 300-60 MG 300-60 MG 180 Tablets 30 DAYS Acetaminophen-Caffeine-Dihydrocodeine Tab 325-30-16 MG 300 Tablets 30 DAYS Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30 MG 50-325-40-30 MG 180 Capsules 30 DAYS Butorphanol Tartrate Nasal Soln 10 MG/ML 10 MG/ML 3 Bottles 30 DAYS Codeine Sulfate Tab 15 MG 15 MG 180 Tablets 30 DAYS Codeine Sulfate Tab 30 MG 30 MG 180 Tablets 30 DAYS Codeine Sulfate Tab 60 MG 60 MG 180 Tablets 30 DAYS Hydrocodone-Acetaminophen Soln 7.5-325 MG/15ML 2.5-108 MG/5ML ; 5-217 MG/10ML ; 7.5-325 MG/15ML 2700 mLs 30 DAYS Hydrocodone-Acetaminophen Tab 10-300 MG 10-300 MG 180 Tablets 30 DAYS Hydrocodone-Acetaminophen Tab 10-325 MG 10-325 MG 180 30 DAYS Hydrocodone-Acetaminophen Tab 5-325 MG 5-325 MG 240 Tablets 30 DAYS Hydrocodone-Acetaminophen Tab 7.5-300 MG 7.5-300 MG 180 Tablets 30 DAYS Hydrocodone-Acetaminophen Tab 7.5-325 MG 7.5-325 MG 180 Tablets 30 DAYS Hydrocodone-Ibuprofen Tab 10-200 MG 10-200 MG 150 Tablets 30 DAYS Hydrocodone-Ibuprofen Tab 5-200 MG 5-200 MG 150 Tablets 30 DAYS Hydrocodone-Ibuprofen Tab 7.5-200 MG 7.5-200 MG 150 Tablets 30 DAYS Levorphanol Tartrate Tab 2 MG
Add Comment