| C |
acetaminophen/ codeine
|
|
|
|
|
|
|
|
| C |
Anexsia® (hydrocodone/APAP)
|
|
|
|
|
|
|
|
| C |
Butorphanol nasal spray
|
|
|
X
|
|
|
|
|
| C |
Butorphanol injection
|
|
|
|
|
|
|
|
| C |
Codeine phosphate/sulfate
|
|
|
|
|
|
|
|
| C |
fentanyl transdermal
|
|
|
X
|
|
|
|
|
| C |
oxycodone
|
|
|
|
|
|
|
|
| C |
oxycodone/ acetaminophen
|
|
|
|
|
|
|
|
| C |
oxycodone/ aspirin
|
|
|
|
|
|
|
|
| C |
Oxyfast® (oxycodone)
|
|
|
|
|
|
|
|
| C |
butalbital/caffeine/codeine/ASA
|
|
|
|
|
|
|
|
| C |
hydrocodone/acetaminophen
|
|
|
|
|
|
|
|
| C |
hydrocodone/acetaminophen solution 10-325MG/15 ml
|
|
|
|
|
|
|
|
| C |
hydrocodone/ibuprofen
|
|
|
|
|
|
|
|
| C |
hydromophone inj, oral solution, supp and tabs
|
|
|
|
|
|
|
|
| C |
Lorcet HD™ (hydrocodone/APAP)
|
|
|
|
|
|
|
|
| C |
meperidine
|
|
|
|
X
|
|
|
|
| C |
methadone
|
|
|
|
|
|
|
|
| C |
morphine, morphine SR
|
|
|
|
|
|
|
|
| C |
Narvox™ (oxycodone/APAP)
|
|
|
|
|
|
|
|
| C |
oxycodone/ibuprofen
|
|
|
X
|
|
|
|
|
| C |
pentazocine/acetaminophen
|
|
|
|
X
|
|
|
|
| C |
pentazocine/naloxone
|
|
|
|
X
|
|
|
|
| C |
propoxyphene HCl
|
|
|
|
X
|
|
|
|
| C |
propoxyphene/aspirin/caffeine
|
|
|
|
X
|
|
|
|
| C |
propoxyphene napsylate/ APAP
|
|
|
|
X
|
|
|
|
| C |
Roxicet™ (oxycodone/ acetaminophen 5/325 tablet)
|
|
|
|
|
|
|
|
| C |
tramadol
|
|
|
|
|
|
|
|
| C |
tramadol/ APAP
|
|
|
|
|
|
|
|
| C |
Trezix™ (dihydrocodeine/APAP/caffeine)
|
|
|
|
|
|
|
|
| C |
Vicodin HP (hydrocodone/APAP)
|
|
|
|
|
|
|
|
| C |
Zerlor™ (APAP/caffeine/dihydocodeine)
|
|
|
|
|
|
|
|
| C |
Balacet®
(propoxyphene-n 100/APAP 325)
|
|
|
|
X
|
|
|
|
| C |
Kadian CR®
(morphine CR)
|
|
|
|
|
|
|
|
| C |
Opana ER®
(oxymorphone SR)
|
|
|
|
|
|
|
|
| C |
Oxycontin CR ®
(oxycodone sr)
|
|
|
X
|
|
|
|
|
| NC |
Alcet®
(oxycodone/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Avinza®
(morphine SR)
|
|
|
|
|
|
X
|
|
| NC |
Bancap-HC®
(hydrocodone/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Capital/Codeine®
(codeine/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Combunox®
(oxycodone 5mg/ ibuprofen 400mg)
|
|
|
X
|
|
X
|
X
|
|
| NC |
Darvocet-N®
(propoxyphene napsylate/APAP)
|
|
|
|
X
|
X
|
X
|
|
| NC |
Darvon-N ®
(propoxyphene napsylate)
|
|
|
|
X
|
X
|
X
|
|
| NC |
Dazidox®
(oxycodone)
|
|
|
|
|
|
X
|
|
| NC |
Demerol®
(meperidine)
|
|
|
|
X
|
|
X
|
|
| NC |
Dilaudid®
(hydromorphone inj, oral solution, supp and tabs )
|
|
|
|
|
|
X
|
|
| NC |
Dolophine®
(methadone)
|
|
|
|
|
|
X
|
|
| NC |
Duragesic®
(fentanyl)
|
|
|
X
|
|
|
X
|
|
| NC |
Fioricet/Codeine®
(butalbital/ APAP/caffeine/codeine)
|
|
|
|
|
X
|
X
|
|
| NC |
Fiorinal/Codeine®
(butalbital/ aspirin/caffeine/codeine)
|
|
|
|
|
X
|
X
|
|
| NC |
Liquicet®
(hydrocodone/APAP 10-500mg/15 ml solution)
|
|
|
|
|
|
X
|
|
| NC |
Lorcet®/ Lorcet Plus
(hydrocodone/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Lortab®
(hydrocodone/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Lynox®
(oxycodone/acetaminophen)
|
|
|
|
|
X
|
X
|
|
| NC |
Magnacet®
(oxycodone/acetaminophen)
|
|
|
|
|
X
|
X
|
|
| NC |
Maxidone®
(hydrocodone/ acetaminophen)
|
|
|
|
|
|
X
|
|
| NC |
MS Contin®
(morphine sulfate er)
|
|
|
|
|
|
X
|
|
| NC |
Norco®
(hydrocodone/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Opana®
(oxymorphone)
|
|
|
X
|
|
X
|
X
|
|
| NC |
Opana inj®
(oxymorphone injection)
|
|
|
|
|
|
X
|
|
| NC |
Oramorph®SR
(morphine sulfate er)
|
|
|
|
|
|
X
|
|
| NC |
OxyIR®
(oxycodone)
|
|
|
|
|
|
X
|
|
| NC |
Panlor DC®
(dihydrocodeine/ APAP/caffeine capsule)
|
|
|
|
|
|
X
|
|
| NC |
Panlor SS®
(dihydrocodeine/ APAP/caffeine tab)
|
|
|
|
|
|
X
|
|
| NC |
Percocet®
(oxycodone/ acetaminophen)
|
|
|
|
|
X
|
X
|
|
| NC |
Percocet®2.5/325 ®
(oxycodone/ acetaminophen)
|
|
|
|
|
|
X
|
|
| NC |
Percodan®
(oxycodone/aspirin)
|
|
|
|
|
X
|
X
|
|
| NC |
Primalev®
(oxycodone w/ acetaminophen)
|
|
|
|
|
X
|
X
|
|
| NC |
Reprexain®
(hydrocodone/ ibuprofen)
|
|
|
|
|
X
|
X
|
|
| NC |
Roxanol®
(morphine sulfate)
|
|
|
|
|
|
X
|
|
| NC |
Roxicet®
(oxycodone/APAP solution and 5/500 tablet)
|
|
|
|
|
|
X
|
|
| NC |
Roxicodone®
(oxycodone)
|
|
|
|
|
|
X
|
|
| NC |
Synalgos® DC
(dihydrocodeine/ APAP/caffeine)
|
|
|
|
|
|
X
|
|
| NC |
Talacen®
(pentazocine/APAP)
|
|
|
|
X
|
X
|
X
|
|
| NC |
Talwin NX®
(pentazocine/naloxone)
|
|
|
|
X
|
|
X
|
|
| NC |
Trycet®
(propoxyphene/APAP)
|
|
|
|
X
|
X
|
X
|
|
| NC |
Tylenol #3®
(codeine/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Tylenol #4®
(codeine/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Tylox®
(oxycodone/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Ultracet®
(tramadol/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Ultram®
(tramadol)
|
|
|
|
|
X
|
X
|
|
| NC |
Ultram ER®
(tramadol)
|
|
|
|
|
|
X
|
|
| NC |
Vicodin / Vicodin ES®
(hydrocodone/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Vicoprofen®
(hydrocodone/ ibuprofen)
|
|
|
|
|
X
|
X
|
|
| NC |
Xodol®
(hydrocodone/APAP)
|
|
|
|
|
X
|
X
|
|
| NC |
Zamicet soln™
(hydrocodone-acetaminophen 10-325mg/15 ml)
|
|
|
|
|
|
X
|
|
| NC |
Zydone®
(hydrocodone/APAP)
|
|
|
|
|
X
|
X
|
|
| Note: Criteria for fentanyl and Duragesic is discussed in the Pharmacy Clinical Policy Bulletin: Duragesic; and Criteria for OxyContin CR is discussed in the Pharmacy Clinical Policy Bulletin: OxyContin CR |
- Precertification Criteria
Under some plans, including plans that use an open or closed formulary, Balacet, butorphanol nasal spray, Combunox, Darvocet-N, Darvon-N, Demerol, meperidine, Opana, oxycodone/ibuprofen, pentazocine/acetaminophen, pentazocine/naloxone, propoxyphene HCL, propoxyphene/aspirin/caffeine, propoxyphene napsylate/acetaminophen, Talacen, Talwin NX and Trycet are subject to precertification. If precertification requirements apply Aetna considers Balacet, butorphanol nasal spray, Combunox, Darvocet-N-100, Darvon-N, Demerol, meperidine, Opana, oxycodone/ibuprofen, pentazocine/acetaminophen, pentazocine/naloxone, propoxyphene HCL, propoxyphene/aspirin/caffeine, propoxyphene napsylate/acetaminophen, Talacen, Talwin NX and Trycet to be medically necessary for those members who meet the following precertification criterion:
A. Quantity limits:
For Butorphanol nasal spray
A. Quantity limits: 2 vials/30 day supply increments
For coverage of additional quantities, a member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit. Additional quantities of butorphanol nasal spray will be considered medically necessary for those members who meet the following criterion:
For Combunox and oxycodone/ibuprofen
A. Quantity limits: 5 mg/400 mg - 120 tablets per 30 days
For coverage of additional tablets, member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit. Additional quantities of Combunox will be considered medically necessary for those members who meet the following criterion:
For Opana*
A. Quantity limits: Opana - 180 tablets per 30 days
For coverage of additional tablets, member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit. Additional quantities of Opana will be considered medically necessary for those members who meet the following criterion:
B. For Balacet, Darvocet-N, Darvon-N, Demerol, meperidine, pentazocine/acetaminophen, pentazocine/naloxone, propoxyphene HCL, propoxyphene/aspirin/caffeine, propoxyphene napsylate/acetaminophen, Talacen, Talwin NX and Trycet