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MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 1 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
This program applies to Medicaid.
FDA APPROVED INDICATIONS AND DOSAGE3-23
Immediate Release Opioid Agents
Indication Dosing
butorphanol nasal spraya
nasal spray
Management of pain
severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
The usual recommended initial dose is
1 mg (1 spray in one nostril). If
adequate pain relief is not achieved
within 60 to 90 minutes, an additional
1 mg dose may be given.
The initial dose sequence outlined
above may be repeated in 3 to 4
hours as required after the second
dose of the sequence.
Depending on the severity of the pain,
an initial dose of 2 mg (1 spray in
each nostril) may be used in patients
who will be able to remain recumbent
in the event drowsiness or dizziness
occurs. In such patients, single
additional 2 mg doses should not be
given for 3 to 4 hours.
codeinea
tablet
Management of mild to
moderate pain, where
treatment with an
opioid is appropriate
and for which
alternative treatments
are inadequate.
15 mg to 60 mg repeated up to every
four hours as needed for pain. The
maximum 24 hour dose is 360 mg.
Dilaudida
(hydromorphone)
tablet,
liquid
Management of pain
severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
Every 4-6 hours
Levorphanola
tablet
management of pain
severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
Every 6-8 hours
Opioid Immediate Release
and Extended Release New To Therapy Program Summary
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 2 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Immediate Release
Opioid Agents
Indication Dosing
Demerola
(meperidine) tablet,
solution
Management of pain,
severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
Every 3-4 hours
Dolophinea
Methadosea
(methadone)
tablet, soluble tablet, solution
Management of pain
severe enough to
require daily, around-
the-clock, long-term
opioid treatment and
for which alternative
treatment options are
inadequate
Every 8-12 hours
morphinea
tablet,
concentrate, solution
Management of
acute and chronic pain severe enough
to require an opioid analgesic and for which alternative
treatments are inadequate.
Every 4 hours
Oxaydo (oxycodone)
tablet
Management of acute
and chronic pain
severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
Every 4-6 hours
oxycodonea
tablet,
solution,
concentrate
Management of pain
severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
Every 4-6 hours
Roxicodonea
(oxycodone)
tablet
Management of pain
severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
Every 4-6 hours
Roxybond (oxycodone)
tablet
Management of pain
severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
Every 4-6 hours
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 3 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Immediate Release
Opioid Agents
Indication Dosing
Opanaa
(oxymorphone) tablet
Management of acute
pain severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
Every 4-6 hours
Nucynta (tapentadol)
tablet
Management of acute
pain severe enough to
require an opioid
analgesic and for which
alternative treatments
are inadequate.
Every 4-6 hours. Daily doses greater
than 700 mg on the first day of
therapy and 600 mg on subsequent
days have not been studied and are
not recommended.
Ultrama (tramadol)
tablet
Management of pain in
adults that is severe
enough to require an
opioid analgesic and for
which alternative
treatments are
inadequate.
Every 4 to 6 hours not to exceed 400
mg/day
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 4 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Combination Opioid
Agents
Strength Dosage & Administration
Reprexain, Ibudone
(hydrocodone/ ibuprofen)
5 mg/200 mg tablet
10 mg/200 mg tablet
One tablet every 4 to 6 hours, as
necessary. Dosage should not exceed 5 tablets in a 24-hour period.
Vicoprofen (hydrocodone/
ibuprofen)
7.5 mg/200 mg tablet
One tablet every 4 to 6 hours, as necessary.
Dosage should not exceed 5 tablets in a 24-hour period.
Ultracet (tramadol/
acetaminophen)
37.5 mg/325 mg tablet
2 tablets every 4 to 6 hours as needed for pain relief,
up to a maximum of 8 tablets per day for up to 5 days.
oxycodone/ aspirin
4.8355 mg/325 mg tablet
One tablet every 6 hours as needed for pain. The maximum daily dose of aspirin
should not exceed 4 grams or 12 tablets.
Apadaz
(benzhydrocodone/
acetaminophen)
4.08/325 mg tablet
6.12/325 mg tablet
8.16/325 mg tablet
1-2 tablets every 4-6 hours. Dosage
should not exceed 12 tablets in a 24
hour period.
Percocet, Endocet (oxycodone/
acetaminophen)
2.5 mg/325 mg tablet
Maximum 12 tablets per day
Percocet, Endocet, Roxicet (oxycodone/
acetaminophen)
5 mg/325 mg tablet Maximum 12 tablets per day
Percocet, Endocet
(oxycodone/ acetaminophen)
7.5 mg/325 mg
tablet
Maximum 8 tablets per day
Percocet, Endocet (oxycodone/
acetaminophen)
10 mg/325 mg tablet Maximum 6 tablets per day
Primlev
(oxycodone/ acetaminophen)
5 mg/300 mg tablet Maximum 12 tablets per day
Primlev (oxycodone/ acetaminophen)
7.5 mg/300 mg tablet
Maximum 8 tablets per day
Primlev (oxycodone/
acetaminophen)
10 mg/300 mg tablet Maximum 6 tablets per day
Roxicet
(oxycodone/ acetaminophen)
5 mg/325 mg/5 mL
solution
Maximum 60 mLs per day
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 5 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Combination Opioid
Agents
Strength Dosage & Administration
Capital and Codeine
(acetaminophen/ codeine)
120 mg/12 mg/5 mL
suspension
Pediatric: 5-10 mLs 3-4 times
daily. Adults: 15 mLs every 4 hours as
needed.
Tylenol w/Codeine (acetaminophen/
codeine)
300 mg/15 mg tablet Maximum 12 tablets per day
Tylenol w/Codeine
(acetaminophen/ codeine)
300 mg/30 mg tablet Maximum 12 tablets per day
Tylenol w/Codeine (acetaminophen/ codeine)
300 mg/60 mg tablet Maximum 6 tablets per day
Hycet (hydrocodone/
acetaminophen)
7.5 mg/325 mg/15 mL solution
Maximum 90 mLs per day
Hydrocodone/
Acetaminophen
2.5 mg/325 mg
tablet
One or two tablets every four to
six hours as needed for pain. The total daily dosage should not exceed 12 tablets.
Norco (hydrocodone/
acetaminophen)
5 mg/325 mg tablet One or two tablets every four to six hours as needed for pain.
The total daily dosage should not exceed 8 tablets.
Norco (hydrocodone/
acetaminophen)
7.5 mg/325 mg tablet
One tablet every four to six hours as needed for pain.
The total daily dosage should not exceed 6 tablets.
Norco (hydrocodone/ acetaminophen)
10 mg/325 mg tablet One tablet every four to six hours as needed for pain. The total daily dosage should not
exceed 5 tablets.
Xodol
(hydrocodone/ acetaminophen)
5 mg/300 mg tablet One or two tablets every four to
six hours as needed for pain. The total daily dosage should not
exceed 8 tablets.
Xodol
(hydrocodone/ acetaminophen)
7.5 mg/300 mg
tablet
One tablet every four to six hours
as needed for pain. The total daily dosage should not exceed 6 tablets.
Xodol (hydrocodone/
acetaminophen)
10 mg/300 mg tablet One tablet every four to six hours as needed for pain.
The total daily dosage should not exceed 6 tablets.
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 6 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Combination Opioid
Agents
Strength Dosage & Administration
Zamicet
(hydrocodone/ acetaminophen)
10 mg/325 mg/15
mL solution
One tablespoonful (15 mL) every
four to six hours as needed for pain. The total daily dosage should not
exceed 6 tablespoonfuls.
Zolvit/Lortab
(hydrocodone/ acetaminophen)
10 mg/300 mg/15
mL solution
Maximum 67.5 mL per day
Trezix, Acetaminophen/
Caffeine/ Dihydrocodeine
320.5 mg/30 mg/16 mg capsule
Two capsules orally every four hours, as needed.
No more than two capsules should be taken in a 4-hour period. No more than five doses, or ten
capsules should be taken in a 24-hour period.
Allzital
(butalbital/
acetaminophen)
25 mg/325 mg tablet 1-2 tablets every four hours as
needed. Do not exceed 6 tablets per
day. Butalbital Compound
(butalbital/
aspirin/
caffeine)
50 mg/325 mg/40 mg
capsule One or 2 tablets every 4 hours as
needed. Total daily dosage should not
exceed 6 tablets.
butalbital/
acetaminophen 50 mg/325 mg tablet One or two tablets every four hours as
needed. Do not exceed not exceed 6
tablets per day. Vanatol LQ
(butalbital/
acetaminophen/
caffeine)
50 mg/325 mg/40
mg/15 mL solution One or two tablespoonfuls (15 mL or
30 mL) every four hours. Total daily
dosage should not exceed 6
tablespoonfuls. Esgic
(butalbital/
acetaminophen/
caffeine)
50 mg/325 mg/40 mg
capsule One or 2 tablets every 4 hours as
needed. Total daily dosage should not
exceed 6 tablets.
Esgic
(butalbital/
acetaminophen/
caffeine)
50 mg/325 mg/40 mg
tablet
One or 2 tablets every 4 hours as
needed. Total daily dosage should not
exceed 6 tablets.
butalbital/ acetaminophen/
caffeine/codeinea
50 mg/325 mg/40 mg/30 mg capsule
One or 2 tablets every 4 hours as needed.
Total daily dosage should not exceed 6 tablets.
Fioricet w/Codeine (butalbital/ acetaminophen/
caffeine/codeine)
50 mg/300 mg/40 mg/30 mg capsule
One or 2 capsules every 4 hours. Total daily dosage should not exceed 6 capsules.
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 7 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Combination Opioid
Agents
Strength Dosage & Administration
Fiorinal w/Codeine
(butalbital/ aspirin/ caffeine/
codeine)a
50 mg/325 mg/40
mg/30 mg capsule
One or 2 tablets every 4 hours as
needed. Total daily dosage should not exceed 6 tablets.
Orbivan
(butalbital/
acetaminophen/
caffeine)
50 mg/300 mg/40 mg
capsule One or 2 capsules every 4 hours as
needed. Total daily dosage should not
exceed 6 capsules.
Bupap, Orbivan CF
(butalbital/
acetaminophen)
50 mg/300 mg tablet One or two tablets every four hours.
Total daily dosage should not exceed
6 tablets.
Pentazocine/naloxonea 50 mg/0.5 mg tablet One or two tablets every 3 to4 hours. Total daily dosage should not exceed 12 tablets
a – generic available
b – discontinued
Opioid Extended
Release Agents Dosing Frequency (Maximum Labeled
Dose)
Indication and Usage
Narcotics
Arymo ER™ (morphine sulfate ER)
15, 30, 60 mg
Two or three times
daily
Management of pain severe
enough to require daily, around-the-clock, long-term opioid
treatment and for which alternative treatment options are
inadequate.
Limitations of Use: • Because of the risks of addiction,
abuse, and misuse with opioids,
even at recommended doses, and
because of the greater risks of
overdose and death with extended-
release opioid formulations, reserve
product for use in patients for
whom alternative treatment options
(e.g., non-opioid analgesics or
immediate-release opioids) are
ineffective, not tolerated, or would
be otherwise inadequate to provide
sufficient management of pain.
Product is not indicated as an as-
needed (prn) analgesic.
Belbuca™ (buprenorphine buccal
film)
75, 150, 300, 450, 600,
750, 900 mcg
Twice daily
(1800 mcg daily)
Butrans
Buprenorphine Transdermal
5, 7.5, 10, 15, 20
mcg/hour system
1 transdermal system weekly
(20 mcg/hr)
Duragesic
(fentanyl transdermal patch ER)
12, 25, 50, 75, 100 mcg/houra
15 patches per
month
Embeda (morphine/naltrexone ER)
Once or twice daily
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 8 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Opioid Extended Release Agents
Dosing Frequency
(Maximum Labeled Dose)
Indication and Usage
20-0.8, 30-1.2, 50-2, 60-2.4,
80-3.2, 100-4 mg
Exalgo (hydromorphone ER)
8, 12, 16, 32 mg
Once daily
Fentanyl transdermal patch
37.5, 62.5, 87.5 mcg/hour
15 patches per
month
Hysingla ER (hydrocodone ER)
20, 30, 40, 60, 80, 100,
120 mg
Once daily
Kadian (morphine ER)a
10, 20, 30, 40, 50, 60,
70, 80, 100, 130, 150, 200 mg
Once or twice daily
Morphabond ER (morphine ER)
15, 30, 60, 100 mg
Twice daily
Morphine Sulfate ER
30, 45, 60, 75, 90, 120 mg
Once daily
(1600 mg daily)
MS Contin (morphine sulfate ER)a
15, 30, 60, 100, 200 mg
Twice daily with some patients
requiring three times daily
Opana ER crush-resistant (oxymorphone ER)
5, 7.5, 10, 15, 20, 30, 40 mg
Twice daily
OxyContin Twice daily
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 9 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Opioid Extended Release Agents
Dosing Frequency
(Maximum Labeled Dose)
Indication and Usage
(oxycodone ER)
Oxymorphone ER
5, 7.5, 10, 15, 20, 30, 40 mg
Twice daily
Xtampza ER (oxycodone ER)
9, 13.5, 18, 27, 36 mg
capsules
Twice daily
(288 mg)
Zohydro ER Abuse Deterrent (hydrocodone ER)
10, 15, 20, 30, 40, 50 mg capsules
Twice daily
Xartemis XR™
(oxycodone/acetaminophen ER)
7.5 mg/325 mg tablet
Twice daily Management of acute pain
severe enough to require opioid treatment and for which
alternative treatment options are inadequate.
Limitations of Use: Because of the risks of addiction,
abuse, misuse, overdose, and death with opioids, even at
recommended doses, reserve oxycodone/acetaminophen ER
for use in patients for whom alternative treatment options
(e.g., non-opioid analgesics) are ineffective, not tolerated, or
would be otherwise inadequate
Tramadol, Tapentadol
Nucynta ER®
(tapentadol ER)
50, 100, 150, 200, 250 mg
Twice daily
(500 mg daily)
Pain severe enough to require daily, around-the-clock, long-
term opioid treatment and for
which alternative treatment options are inadequate.
Neuropathic pain associated with
diabetic peripheral neuropathy
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 10 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Opioid Extended Release Agents
Dosing Frequency
(Maximum Labeled Dose)
Indication and Usage
(DPN) in adults severe enough
to require daily, around-the-clock, long-term opioid
treatment and for which alternative treatment options are
inadequate.
Because of the risks of addiction,
abuse, and misuse with opioids, even at recommended doses,
and because of the greater risks of overdose and death with
extended-release opioid formulations, reserve tapentadol
ER for use in patients for whom alternative treatment options
(e.g., nonopioid analgesics or immediate-release opioids) are
ineffective, not tolerated, or would be otherwise inadequate
to provide sufficient management of pain.
Tapentadol ER is not indicated as an as-needed (prn) analgesic.
Conzip (tramadol SR biphasic)
100, 200, 300 mg
Once daily
(300 mg daily)
Management of moderate to
moderately severe chronic pain in adults who require around-
the-clock treatment of their pain for an extended period of time tramadol ERa
100, 200, 300 mg
Once daily
(300 mg daily)
Tramadol SR Biphasic
(tramadol SR biphasic)
150 mg
Once daily
(300 mg daily)
Ultram ER (tramadol ER)a
100, 200, 300 mg
Once daily
(300 mg daily)
a – generic available
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 11 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
CLINICAL RATIONALE
The Center for Disease Control and Prevention recommends that when opioids are used
for acute pain, clinicians should prescribe the lowest effective dose of immediate-release
opioids and should prescribe no greater quantity than needed for the expected duration
of pain severe enough to require opioids. Three days or less will often be sufficient; more
than seven days will rarely be needed.1
When starting opioid therapy for chronic pain, clinicians should prescribe immediate-
release opioids instead of extended-release/long-acting (ER/LA) opioids. ER/LA opioids
should be reserved for severe, continuous pain and should be considered only for
patients who have received immediate-release opioids daily for at least 1 week.1
Use of tramadol or codeine containing products in pediatric patients has cause life-
threatening respiratory depression, with some of the reported cases occurring post-
tonsillectomy and/or adenoidectomy. Ultra-rapid metabolizers are at increased risk of
life-threatening respiratory depression due to a CYP2D6 polymorphism. Use in children
under 12 years of age is contraindicated for these products, and for those between the
ages of 12 and 18 years when used for post-operative pain management following
tonsillectomy and/or adenoidectomy.2
REFERENCES
1. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.
Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report.
65(1);1–49. March 18, 2016
2. FDA Drug Safety Communication: FDA restricts use of prescription codeine pain
and cough medicines and tramadol pain medicines in children; recommends
against use in breastfeeding women. April 2017.
3. butorphanol tartrate nasal solution prescribing information. Apotex Corp. August
2018.
4. codeine prescribing information. Lannett Company, Inc. September 2018.
5. meperidine prescribing information. Sanofi-Aventis US. LLC. September 2018.
6. Dilaudid prescribing information. Purdue Pharma LP. September 2018.
7. Dolophine prescribing information. West-Ward Pharmaceuticals Corp. September
2018.
8. levorphanol prescribing information. Roxane Laboratories, Inc. September 2018.
9. methadone prescribing information. Cerbert Pharmaceuticals. May 2008.
10. Methadose prescribing information. Mallinkrodt, Inc. April 2018.
11. morphine prescribing information. West-Ward Pharmaceuticals Corp. April 2017.
12. oxycodone prescribing information. Amneal Pharmaceuticals LLC. June 2017.
13. Opana prescribing information. Endo Pharmaceuticals. September 2018.
14. Oxaydo prescribing information. Egalet US Inc. September 2018.
15. Nucynta prescribing information. Janssen Pharmaceuticals, Inc. September 2018.
16. Ultram prescribing information. Janssen Pharms. September 2018.
17. Roxybond prescribing information. Daiichi Sankyo Inc. September 2018.
18. Roxicodone prescribing information. Specgx LLC. September 2018.
19. Combunox prescribing information. Forest Pharmaceuticals, Inc. September 2010.
20. DailyMed. UN National Library of Medicine. Accessed 10/15/2018.
https://dailymed.nlm.nih.gov/dailymed/index.cfm
21. Ultracet prescribing information. Janssen Pharmaceuticals, Inc. August 2017.
22. Tylenol with codeine prescribing information. Janssen Pharmaceuticals, Inc. April
2018.
23. Apadaz prescribing information. KemPharm, Inc. September 2018.
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 12 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
Opioids IR and ER New To Therapy
OBJECTIVE
The intent of the program is to help direct appropriate use of opioids based on the CDC
guideline recommendation that acute use of these agents should rarely exceed 7 days of
therapy. The program will check if a patient is new to opioid therapy as defined as having
no prior opioid use in the past 120 days. If the patient is new to therapy, the patient will
be restricted to ≤7 days of therapy. The program will allow for uses beyond this limit if
the patient has a diagnosis of cancer pain due to an active malignancy, is taking an
oncology agent in the past 120 days, is eligible for hospice care, or has provided
documentation showing use beyond this limit is appropriate. Tramadol or codeine
containing agents will not be approved for pediatric patients less than 12 years of age,
nor for patients less than 18 years of age for post-operative pain management following
a tonsillectomy and/or adenoidectomy.
TARGET AGENTS FOR NEW TO THERAPYa
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
butorphanol 10 mg/mL nasal
spray
65200020102050 G M,N,O,Y
Codeine 15 mg tablet 65100020200305 B M,N,O,Y
Codeine 30 mg tablet 65100020200310 BG M,N,O,Y
Codeine 60 mg tablet 65100020200315 B M,N,O,Y
Dilaudid
(hydromorphone
)
2 mg tablet 65100035100310 BG M,N,O,Y
Dilaudid
(hydromorphone
)
4 mg tablet 65100035100320 BG M,N,O,Y
Dilaudid
(hydromorphone
)
8 mg tablet 65100035100330 BG M,N,O,Y
Dilaudid
(hydromorphone
)
1 mg/mL liquid 65100035100920 BG M,N,O,Y
Levorphanol 2 mg tablet 65100040100305 G M,N,O,Y
Levorphanol 3 mg tablet 65100040100310 B M,N,O,Y
meperidine 50 mg tablet 65100045100305 BG M,N,O,Y
Demerol
(meperidine)
100 mg tablet 65100045100310 BG M,N,O,Y
Meperidine 50 mg/5 mL solution 65100045102060 B M,N,O,Y
Dolophine
(methadone)
5 mg tablet 65100050100305 BG M,N,O,Y
Dolophine
(methadone)
10 mg tablet 65100050100310 BG M,N,O,Y
Methadose
(methadone
40 mg soluble tablet 65100050107320 G M,N,O,Y
methadone 5 mg/5mL solution 65100050102010 BG M,N,O,Y
methadone 10 mg/5 mL solution 65100050102015 BG M,N,O,Y
methadone 10 mg/mL
concentrate
65100050101310 BG M,N,O,Y
Morphine 15 mg tablet 65100055100310 B M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 13 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
Morphine 30 mg tablet 65100055100315 B M,N,O,Y
Morphine 10 mg/5 mL solution 65100055102065 G M,N,O,Y
Morphine 20 mg/5 mL solution 65100055102070 G M,N,O,Y
Morphine 20 mg/mL
concentrate
65100055102090 G M,N,O,Y
oxycodone 5 mg capsule 65100075100110 G M,N,O,Y
Oxaydo,
Roxybond
(oxycodone)
5 mg tablet 6510007510A510 B M,N,O,Y
Oxaydo
(oxycodone)
7.5 mg tablet 6510007510A520 B M,N,O,Y
oxycodone 10 mg tablet 65100075100320 G M,N,O,Y
oxycodone 20 mg tablet 65100075100330 G M,N,O,Y
oxycodone 5 mg/5mL solution 65100075102005 G M,N,O,Y
oxycodone 20 mg/mL
concentrate
65100075101320 G M,N,O,Y
Roxicodone
(oxycodone)
5 mg tablet 65100075100310 BG M,N,O,Y
Roxicodone
(oxycodone)
15 mg tablet 65100075100325 BG M,N,O,Y
Roxybond
(oxycodone)
15 mg tablet 6510007510A540 B M,N,O,Y
Roxybond
(oxycodone)
30 mg tablet 6510007510A560 B M,N,O,Y
Roxicodone
(oxycodone)
30 mg tablet 65100075100340 BG M,N,O,Y
Opana
(oxymorphone)
5 mg tablet 65100080100305 BG M,N,O,Y
Opana
(oxymorphone)
10 mg tablet 65100080100310 BG M,N,O,Y
Nucynta
(tapentadol)
50 mg tablet 65100091100320 B M,N,O,Y
Nucynta
(tapentadol)
75 mg tablet 65100091100330 B M,N,O,Y
Nucynta
(tapentadol)
100 mg tablet 65100091100340 B M,N,O,Y
Ultram
(tramadol)
50 mg tablet 65100095100320 BG M,N,O,Y
Combination Agents
Oxycodone/
Ibuprofen
5 mg/400 mg tablet 65990002260320 B M,N,O,Y
Reprexain
(hydrocodone/
ibuprofen)
2.5 mg/200 mg
tablet
65991702500310 DC M,N,O,Y
Reprexain,
Ibudone
(hydrocodone/
ibuprofen)
5 mg/200 mg tablet 65991702500315 BG M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 14 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
Reprexain,
Ibudone, Xylon
(hydrocodone/
ibuprofen)
10 mg/200 mg
tablet
65991702500330 BG M,N,O,Y
Vicoprofen
(hydrocodone/
ibuprofen)
7.5 mg/200 mg
tablet
65991702500320 G M,N,O,Y
Ultracet
(tramadol/
acetaminophen)
37.5 mg/325 mg
tablet
65995002200320 BG M,N,O,Y
Percodan,
Endodan
(oxycodone/
aspirin)
4.8355 mg/325 mg
tablet
65990002220340 G M,N,O,Y
Synalgos-DC,
Aspirin/Caffeine/
Dihydrocodeine
356.4 mg/30 mg/16
mg capsule
65991303100115 B M,N,O,Y
Apadaz
(benzhydrocodon
e/acetaminophen
4.08/325 mg tablet 65990002020310 B M,N,O,Y
Apadaz
(benzhydrocodon
e/acetaminophen
6.12/325 mg tablet 65990002020320 B M,N,O,Y
Apadaz
(benzhydrocodon
e/acetaminophen
8.16/325 mg tablet 65990002020330 B M,N,O,Y
Percocet,
Endocet
(oxycodone/
acetaminophen)
2.5 mg/325 mg
tablet
65990002200305 BG M,N,O,Y
Percocet,
Endocet, Roxicet
(oxycodone/
acetaminophen)
5 mg/325 mg tablet 65990002200310 BG M,N,O,Y
Percocet,
Endocet
(oxycodone/
acetaminophen)
7.5 mg/325 mg
tablet
65990002200327 BG M,N,O,Y
Percocet,
Endocet
(oxycodone/
acetaminophen)
10 mg/325 mg
tablet
65990002200335 BG M,N,O,Y
Nalocet
(oxycodone/
acetaminophen)
2.5 mg/300 mg
tablet
65990002200303 B M,N,O,Y
Primlev
(oxycodone/
acetaminophen)
5 mg/300 mg tablet 65990002200308 B M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 15 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
Primlev
(oxycodone/
acetaminophen)
7.5 mg/300 mg
tablet
65990002200325 B M,N,O,Y
Primlev
(oxycodone/
acetaminophen)
10 mg/300 mg
tablet
65990002200333 B M,N,O,Y
Roxicet
(oxycodone/
acetaminophen)
5 mg/325 mg/5 mL
solution
65990002202005 B M,N,O,Y
Capital and
Codeine
(acetaminophen/
codeine)
120 mg/12 mg/5 mL
suspension
65991002051805 B M,N,O,Y
Acetaminophen/
codeine
120 mg/12 mg/5 mL
solution
65991002052020 G M,N,O,Y
Tylenol
w/Codeine
(acetaminophen/
codeine)
300 mg/15 mg
tablet
65991002050310 BG M,N,O,Y
Tylenol
w/Codeine
(acetaminophen/
codeine)
300 mg/30 mg
tablet
65991002050315 BG M,N,O,Y
Tylenol
w/Codeine
(acetaminophen/
codeine)
300 mg/60 mg
tablet
65991002050320 BG M,N,O,Y
Hycet
(hydrocodone/
acetaminophen)
7.5 mg/325 mg/15
mL solution
65991702102015 G M,N,O,Y
Hydrocodone/
acetaminophen
2.5 mg/325 mg
tablet
65991702100302 G M,N,O,Y
Norco
(hydrocodone/
acetaminophen)
5 mg/325 mg tablet 65991702100356 BG M,N,O,Y
Norco
(hydrocodone/
acetaminophen)
7.5 mg/325 mg
tablet
65991702100358 BG M,N,O,Y
Norco
(hydrocodone/
acetaminophen)
10 mg/325 mg
tablet
65991702100305 BG M,N,O,Y
Xodol
(hydrocodone/
acetaminophen)
5 mg/300 mg tablet 65991702100309 BG M,N,O,Y
Xodol
(hydrocodone/
acetaminophen)
7.5 mg/300 mg
tablet
65991702100322 BG M,N,O,Y
Xodol
(hydrocodone/
acetaminophen)
10 mg/300 mg
tablet
65991702100375 BG M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 16 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
hydrocodone/
acetaminophen
solution
10 mg/325 mg/15
mL solution
65991702102025 BG M,N,O,Y
Zolvit/Lortab
(hydrocodone/
acetaminophen)
10 mg/300 mg/15
mL solution
65991702102024 B M,N,O,Y
Trezix,
Acetaminophen/
Caffeine/
Dihydrocodeine
320.5 mg/30 mg/16
mg capsule
65991303050115 B M,N,O,Y
Panlor,
(acetaminophen/
caffeine/dihydroc
odeine)
325 mg/30 mg/16
mg tablet
65991303050320 G M,N,O,Y
Fioricet
w/Codeine
(butalbital/
acetaminophen/
caffeine/codeine)
50 mg/325 mg/40
mg/30 mg capsule
65991004100115 G M,N,O,Y
Fioricet
w/Codeine
(butalbital/
acetaminophen/
caffeine/codeine)
50 mg/300 mg/40
mg/30 mg capsule
65991004100113 BG M,N,O,Y
Fiorinal
w/Codeine
(butalbital/
aspirin/caffeine/
codeine)
50 mg/325 mg/40
mg/30 mg capsule
65991004300115 BG M,N,O,Y
Oxycodone/
Ibuprofen
5 mg/400 mg tablet 65990002260320 B M,N,O,Y
Reprexain
(hydrocodone/
ibuprofen)
2.5 mg/200 mg
tablet
65991702500310 BG M,N,O,Y
Reprexain,
Ibudone
(hydrocodone/
ibuprofen)
5 mg/200 mg tablet 65991702500315 BG M,N,O,Y
pentazocine/nalo
xone
50 mg/0.5 mg tablet 65200040300310 G M,N,O,Y
Opioid ER Agents
Arymo ER
(morphine
sulfate)
15 mg extended
release tablet
6510005510A620 B M,N,O,Y
Arymo ER
(morphine
sulfate)
30 mg extended
release tablet
6510005510A630 B M,N,O,Y
Arymo ER
(morphine
sulfate)
60 mg extended
release tablet
6510005510A640 B M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 17 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
Belbuca
(buprenorphine
buccal film)
75 mcg buccal film 65200010108210 B M,N,O,Y
Belbuca
(buprenorphine
buccal film)
150 mcg buccal film 65200010108220 B M,N,O,Y
Belbuca
(buprenorphine
buccal film)
300 mcg buccal film 65200010108230 B M,N,O,Y
Belbuca
(buprenorphine
buccal film)
450 mcg buccal film 65200010108240 B M,N,O,Y
Belbuca
(buprenorphine
buccal film)
600 mcg buccal film 65200010108250 B M,N,O,Y
Belbuca
(buprenorphine
buccal film)
750 mcg buccal film 65200010108260 B M,N,O,Y
Belbuca
(buprenorphine
buccal film)
900 mcg buccal film 65200010108270 B M,N,O,Y
Butrans,
Buprenorphine
Transdermal
System
5 mcg/hour
transdermal system
65200010008820 BG M,N,O,Y
Butrans,
Buprenorphine
Transdermal
System
7.5 mcg/hour
transdermal system
65200010008825 BG M,N,O,Y
Butrans,
Buprenorphine
Transdermal
System
10 mcg/hour
transdermal system
65200010008830 BG M,N,O,Y
Butrans,
Buprenorphine
Transdermal
System
15 mcg/hour
transdermal system
65200010008835 BG M,N,O,Y
Butrans,
Buprenorphine
Transdermal
System
20 mcg/hour
transdermal system
65200010008840 BG M,N,O,Y
Duragesic
(fentanyl
transdermal
patch)
12 mcg/hr
transdermal patch
65100025008610 BG M,N,O,Y
Duragesic
(fentanyl
transdermal
patch)
25 mcg/hr
transdermal patch
65100025008620 BG M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 18 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
Duragesic
(fentanyl
transdermal
patch)
50 mcg/hr
transdermal patch
65100025008630 BG M,N,O,Y
Duragesic
(fentanyl
transdermal
patch)
75 mcg/hr
transdermal patch
65100025008640 BG M,N,O,Y
Duragesic
(fentanyl
transdermal
patch)
100 mcg/hr
transdermal patch
65100025008650 BG M,N,O,Y
Embeda
(morphine/naltre
xone)
20 mg/0.8 mg
controlled-release
capsule
65100055700220 B M,N,O,Y
Embeda
(morphine/naltre
xone)
30 mg/1.2 mg
controlled-release
capsule
65100055700230 B M,N,O,Y
Embeda
(morphine/naltre
xone)
50 mg/2 mg
controlled-release
capsule
65100055700240 B M,N,O,Y
Embeda
(morphine/naltre
xone)
60 mg/2.4 mg
controlled-release
capsule
65100055700250 B M,N,O,Y
Embeda
(morphine/naltre
xone)
80 mg/3.2 mg
controlled-release
capsule
65100055700260 B M,N,O,Y
Embeda
(morphine/naltre
xone)
100 mg/4 mg
controlled-release
capsule
65100055700270 B M,N,O,Y
Exalgo (hydromorphone)
8 mg extended-
release tablet
6510003510A820 BG M,N,O,Y
Exalgo (hydromorphone)
12 mg extended-
release tablet
6510003510A830 BG M,N,O,Y
Exalgo (hydromorphone)
16 mg extended-
release tablet
6510003510A840 BG M,N,O,Y
Exalgo (hydromorphone)
32 mg extended-
release tablet
6510003510A855 BG M,N,O,Y
Fentanyl
transdermal
patch
37.5 mcg/hr
transdermal patch
65100025008626 G M,N,O,Y
Fentanyl
transdermal
patch
62.5 mcg/hr
transdermal patch
65100025008635 G M,N,O,Y
Fentanyl
transdermal
patch
87.5 mcg/hr
transdermal patch
65100025008645 G M,N,O,Y
Hysingla ER
(hydrocodone)
20 mg extended-
release tablet
6510003010A810 B M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 19 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
Hysingla ER
(hydrocodone)
30 mg extended-
release tablet
6510003010A820 B M,N,O,Y
Hysingla ER
(hydrocodone)
40 mg extended-
release tablet
6510003010A830 B M,N,O,Y
Hysingla ER
(hydrocodone)
60 mg extended-
release tablet
6510003010A840 B M,N,O,Y
Hysingla ER
(hydrocodone)
80 mg extended-
release tablet
6510003010A850 B M,N,O,Y
Hysingla ER
(hydrocodone)
100 mg extended-
release tablet
6510003010A860 B M,N,O,Y
Hysingla ER
(hydrocodone)
120 mg extended-
release tablet
6510003010A870 B M,N,O,Y
Kadian
(morphine
sulfate)
10 mg sustained-
release capsule
65100055107010 BG M,N,O,Y
Kadian
(morphine
sulfate)
20 mg sustained-
release capsule
65100055107020 BG M,N,O,Y
Kadian
(morphine
sulfate)
30 mg sustained-
release capsule
65100055107030 BG M,N,O,Y
Kadian
(morphine
sulfate)
40 mg sustained-
release capsule
65100055107035 BG M,N,O,Y
Kadian
(morphine
sulfate)
50 mg sustained-
release capsule
65100055107040 BG M,N,O,Y
Kadian
(morphine
sulfate)
60 mg sustained-
release capsule
65100055107045 BG M,N,O,Y
Kadian
(morphine
sulfate)
70 mg sustained-
release capsule
65100055107047 DC M,N,O,Y
Kadian
(morphine
sulfate)
80 mg sustained-
release capsule
65100055107050 BG M,N,O,Y
Kadian
(morphine
sulfate)
100 mg sustained-
release capsule
65100055107060 BG M,N,O,Y
Kadian
(morphine
sulfate)
130 mg sustained-
release capsule
65100055107070 DC M,N,O,Y
Kadian
(morphine
sulfate)
150 mg sustained-
release capsule
65100055107074 DC M,N,O,Y
Kadian
(morphine
sulfate)
200 mg sustained-
release capsule
65100055107080 B M,N,O,Y
Morphabond ER
(morphine ER)
15 mg ER tablet 6510005510A720 B M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 20 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
Morphabond ER
(morphine ER)
30 mg ER tablet 6510005510A730 B M,N,O,Y
Morphabond ER
(morphine ER)
60 mg ER tablet 6510005510A740 B M,N,O,Y
Morphabond ER
(morphine ER)
100 mg ER tablet 6510005510A760 B M,N,O,Y
morphine sulfate
ER
30 mg sustained-
release capsule
65100055207020 B M,N,O,Y
morphine sulfate
ER
45 mg sustained-
release capsule
65100055207025 B M,N,O,Y
morphine sulfate
ER
60 mg sustained-
release capsule
65100055207030 B M,N,O,Y
morphine sulfate
ER
75 mg sustained-
release capsule
65100055207035 B M,N,O,Y
morphine sulfate
ER
90 mg sustained-
release capsule
65100055207040 B M,N,O,Y
morphine sulfate
ER
120 mg sustained-
release capsule
65100055207050 B M,N,O,Y
MS Contin
(morphine
sulfate)
15 mg sustained-
release tablet
65100055100415 BG M,N,O,Y
MS Contin
(morphine
sulfate)
30 mg sustained-
release tablet
65100055100432 BG M,N,O,Y
MS Contin
(morphine
sulfate)
60 mg sustained-
release tablet
65100055100445 BG M,N,O,Y
MS Contin
(morphine
sulfate)
100 mg sustained-
release tablet
65100055100460 BG M,N,O,Y
MS Contin
(morphine
sulfate)
200 mg sustained-
release tablet
65100055100480 BG M,N,O,Y
Opana ER
(oxymorphone
SR, crush
resistant)
5 mg sustained-
release tablet
6510008010A705 B M,N,O,Y
Opana ER
(oxymorphone
SR, crush
resistant)
7.5 mg sustained-
release tablet
6510008010A707 B M,N,O,Y
Opana ER
(oxymorphone
SR, crush
resistant)
10 mg sustained-
release tablet
6510008010A710 B M,N,O,Y
Opana ER
(oxymorphone
SR, crush
resistant)
15 mg sustained-
release tablet
6510008010A715 B M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 21 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
Opana ER
(oxymorphone
SR, crush
resistant)
20 mg sustained-
release tablet
6510008010A720 B M,N,O,Y
Opana ER
(oxymorphone
SR, crush
resistant)
30 mg sustained-
release tablet
6510008010A730 B M,N,O,Y
Opana ER
(oxymorphone
SR, crush
resistant)
40 mg sustained-
release tablet
6510008010A740 B M,N,O,Y
OxyContin
(oxycodone ER)
10 mg tablet 6510007510A710 B M,N,O,Y
OxyContin
(oxycodone ER)
15 mg tablet 6510007510A715 B M,N,O,Y
OxyContin
(oxycodone ER)
20 mg tablet 6510007510A720 B M,N,O,Y
OxyContin
(oxycodone ER)
30 mg tablet 6510007510A730 B M,N,O,Y
OxyContin
(oxycodone ER)
40 mg tablet 6510007510A740 B M,N,O,Y
OxyContin
(oxycodone ER)
60 mg tablet 6510007510A760 B M,N,O,Y
OxyContin
(oxycodone ER)
80 mg tablet 6510007510A780 B M,N,O,Y
Oxymorphone SR
5 mg sustained-
release tablet
65100080107405 B M,N,O,Y
Oxymorphone SR 7.5 mg sustained-
release tablet
65100080107407 B M,N,O,Y
Oxymorphone SR 10 mg sustained-
release tablet
65100080107410 B M,N,O,Y
Oxymorphone SR 15 mg sustained-
release tablet
65100080107415 B M,N,O,Y
Oxymorphone SR 20 mg sustained-
release tablet
65100080107420 B M,N,O,Y
Oxymorphone SR 30 mg sustained-
release tablet
65100080107430 B M,N,O,Y
Oxymorphone SR 40 mg sustained-
release tablet
65100080107440 B M,N,O,Y
Xartemis XR
(oxycodone/acet
aminophen)
7.5/325 mg tablet 65990002200430 B M,N,O,Y
Xtampza ER
(oxycodone ER)
9 mg capsule 6510007500A310 B M,N,O,Y
Xtampza ER
(oxycodone ER)
13.5 mg capsule 6510007500A315 B M,N,O,Y
Xtampza ER
(oxycodone ER)
18 mg capsule 6510007500A320 B M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 22 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
Xtampza ER
(oxycodone ER)
27 mg capsule 6510007500A330 B M,N,O,Y
Xtampza ER
(oxycodone ER)
36 mg capsule 6510007500A340 B M,N,O,Y
Zohydro ER
Abuse Deterrent
(hydrocodone
ER)
10 mg sustained-
release capsule
6510003010A310 B M,N,O,Y
Zohydro ER
Abuse Deterrent
(hydrocodone
ER)
15 mg sustained-
release capsule
6510003010A315 B M,N,O,Y
Zohydro ER
Abuse Deterrent
(hydrocodone
ER)
20 mg sustained-
release capsule
6510003010A320 B M,N,O,Y
Zohydro ER
Abuse Deterrent
(hydrocodone
ER)
30 mg sustained-
release capsule
6510003010A330 B M,N,O,Y
Zohydro ER
Abuse Deterrent
(hydrocodone
ER)
40 mg sustained-
release capsule
6510003010A340 B M,N,O,Y
Zohydro ER
Abuse Deterrent
(hydrocodone
ER)
50 mg sustained-
release capsule
6510003010A350 B M,N,O,Y
ConZip
(tramadol SR
biphasic)
100 mg sustained-
release capsule
65100095107070 B M,N,O,Y
ConZip
(tramadol SR
biphasic)
200 mg sustained-
release capsule
65100095107080 B M,N,O,Y
ConZip
(tramadol SR
biphasic)
300 mg sustained-
release capsule
65100095107090 B M,N,O,Y
Nucynta ER
(tapentadol SR)
50 mg extended-
release tablet
65100091107420 B M,N,O,Y
Nucynta ER
(tapentadol SR)
100 mg extended-
release tablet
65100091107430 B M,N,O,Y
Nucynta ER
(tapentadol SR)
150 mg extended-
release tablet
65100091107440 B M,N,O,Y
Nucynta ER
(tapentadol SR)
200 mg extended-
release tablet
65100091107450 B M,N,O,Y
Nucynta ER
(tapentadol SR)
250 mg extended-
release tablet
65100091107460 B M,N,O,Y
tramadol 100 mg sustained-
release tablet
65100095107560 G M,N,O,Y
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 23 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
AGENT Strength GPI Brand,
Generic
Availability
Multi-
source
Code
tramadol 200 mg sustained-
release tablet
65100095107570 G M,N,O,Y
tramadol 300 mg sustained-
release tablet
65100095107580 G M,N,O,Y
Tramadol ER
(tramadol SR
biphasic)
150 mg sustained-
release capsule
65100095107075 B M,N,O,Y
Ultram ER
(tramadol)
100 mg sustained-
release tablet
65100095107520 G M,N,O,Y
Ultram ER
(tramadol)
200 mg sustained-
release tablet
65100095107530 G M,N,O,Y
Ultram ER
(tramadol)
300 mg sustained-
release tablet
65100095107540 G M,N,O,Y
a – all target agents are subject to a ≤ 7 days of therapy if no prior opioid or oncology claims are found in the past 120 days
PRIOR AUTHORIZATION CRITERIA FOR APPROVAL
TARGETED AGENT(S) will be approved for above the 7 days supply limit when BOTH of
the following are met:
1. ONE of the following:
a. There is documentation that the patient is not new to opioid therapy in the
past 120 days
OR
b. There is documentation that the patient has taken an oncology agent in
the past 120 days
OR
c. The prescriber states the patient is NOT new to opioids therapy AND is at
risk if therapy is changed
OR
d. The patient has a diagnosis of chronic cancer pain due to an active
malignancy
OR
e. The patient is eligible for hospice care
OR
f. ALL of the following
i. The prescriber has provided documentation in support of use of
opioids for an extended duration (>7 days)
AND
ii. The prescriber provides documentation of a formal, consultative
evaluation including:
1. Diagnosis
AND
2. A complete medical history which includes previous and
current pharmacological and non-pharmacological therapy
AND
iii. The prescriber has confirmed that a patient-specific pain
management plan is on file for the patient
AND
MN_Medicaid_CS_Opioids_IR_ER_NTT_ProgSum_AR0219_r0219 Page 24 of 24
© Copyright Prime Therapeutics LLC. 02/2019 All Rights Reserved
iv. The prescriber has confirmed that the patient is not diverting the
requested medication, according to the patient’s records in the
state’s prescription drug monitoring program (PDMP), if applicable
AND
2. ONE of the following:
a. The requested agent does not contain tramadol or codeine
OR
b. The requested agent contains tramadol or codeine AND ONE of the
following:
i. The patient is 18 years of age or older
OR
ii. The patient is between 12 and 18 years of age AND the requested
agent will NOT be used for post-operative pain management
following a tonsillectomy and/or adenoidectomy
Length of approval: 1 month
NOTE: If other programs (e.g. Quantity Limits, Step Therapy) also applies, please refer
to program specific documents.