2023 Medication Search - Peoples Health Medicare Advantage in Louisiana

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Your doctor may need to provide additional information to your pharmacist when you fill a prescription for this drug. Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME) and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

Denotes a drug that is not covered.

APAP/CODEINE SOL 120-12/5
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 4500 per 30-days (* depending on package size)
APAP/CODEINE SOL 300-30MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 4500 per 30-days (* depending on package size)
APAP/CODEINE TAB 300-15MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 390 per 30-days (* depending on package size)
APAP/CODEINE TAB 300-30MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 390 per 30-days (* depending on package size)
APAP/CODEINE TAB 300-60MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 390 per 30-days (* depending on package size)
APAP-CAFFEIN CAP DIHYDROC
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 300 per 30-days (* depending on package size)
BAC TAB
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
BUT/APAP/CAF TAB
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
BUT/ASA/CAFF CAP
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
BUTORPHANOL INJ 1MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
BUTORPHANOL INJ 2MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
BUTORPHANOL SOL 10MG/ML
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 5 per 30-days (* depending on package size)
CODEINE SULF TAB 15MG
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
CODEINE SULF TAB 30MG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
CODEINE SULF TAB 60MG
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
DURAMORPH INJ 0.5MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
DURAMORPH INJ 1MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
ENDOCET TAB 10-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
ENDOCET TAB 2.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
ENDOCET TAB 5-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
ENDOCET TAB 7.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
FENTANYL CIT INJ 0.05MG/1
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 100/2ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 1000/20
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 1000MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 100MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 250/5ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 2500/50
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 2500MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 250MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 500MCG
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL CIT INJ 50MCG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Prior Authorization: Part B vs. Part D Prior Authorization
FENTANYL OT LOZ 1200MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
FENTANYL OT LOZ 1600MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
FENTANYL OT LOZ 200MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
FENTANYL OT LOZ 400MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
FENTANYL OT LOZ 600MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
FENTANYL OT LOZ 800MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
HYDROCO/APAP SOL 5-217MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 5400 per 30-days (* depending on package size)
HYDROCO/APAP SOL 7.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 5400 per 30-days (* depending on package size)
HYDROCO/APAP TAB 10-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
HYDROCO/APAP TAB 5-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
HYDROCO/APAP TAB 7.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
HYDROCOD/IBU TAB 7.5-200
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 150 per 30-days (* depending on package size)
HYDROMORPHON INJ 0.5/0.5
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
HYDROMORPHON INJ 10MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
HYDROMORPHON INJ 1MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
HYDROMORPHON INJ 2MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
HYDROMORPHON INJ 4MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
HYDROMORPHON INJ 500/50ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
HYDROMORPHON INJ 50MG/5ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
HYDROMORPHON LIQ 1MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 1500 per 30-days (* depending on package size)
HYDROMORPHON TAB 2MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 240 per 30-days (* depending on package size)
HYDROMORPHON TAB 4MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 240 per 30-days (* depending on package size)
HYDROMORPHON TAB 8MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
MORPHIN/NACL INJ 30/30ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
MORPHINE SUL INJ 0.5MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
MORPHINE SUL INJ 10MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
MORPHINE SUL INJ 1MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
MORPHINE SUL INJ 2MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
MORPHINE SUL INJ 4MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
MORPHINE SUL INJ 5MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
MORPHINE SUL INJ 8MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
MORPHINE SUL SOL 100/5ML
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 300 per 30-days (* depending on package size)
MORPHINE SUL SOL 10MG/5ML
Classification: Tier 3 (preferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 3000 per 30-days (* depending on package size)
MORPHINE SUL SOL 20MG/5ML
Classification: Tier 3 (preferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 1500 per 30-days (* depending on package size)
MORPHINE SUL SOL 20MG/ML
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 300 per 30-days (* depending on package size)
MORPHINE SUL TAB 15MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 240 per 30-days (* depending on package size)
MORPHINE SUL TAB 30MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
NALBUPHINE INJ 10MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
NALBUPHINE INJ 20MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
OXYCOD/APAP TAB 10-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
OXYCOD/APAP TAB 2.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
OXYCOD/APAP TAB 5-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
OXYCOD/APAP TAB 7.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
OXYCODONE CON 10/0.5ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
OXYCODONE CON 100/5ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
OXYCODONE SOL 5MG/5ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 3900 per 30-days (* depending on package size)
OXYCODONE TAB 10MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
OXYCODONE TAB 15MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 240 per 30-days (* depending on package size)
OXYCODONE TAB 20MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
OXYCODONE TAB 30MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 180 per 30-days (* depending on package size)
OXYCODONE TAB 5MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 360 per 30-days (* depending on package size)
TRAMADL/APAP TAB 37.5-325
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 240 per 30-days (* depending on package size)
TRAMADOL HCL TAB 50MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
Quantity Limit: 240 per 30-days (* depending on package size)
ACTIQ LOZ 1200MCG
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
ACTIQ LOZ 200MCG
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
ACTIQ LOZ 400MCG
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
ACTIQ LOZ 600MCG
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
ACTIQ LOZ 800MCG
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
ALLZITAL TAB 25-325MG
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
APADAZ TAB 4.08-325
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
APADAZ TAB 6.12-325
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
APADAZ TAB 8.16-325
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
ASCOMP/COD CAP 30MG
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
BENZHY/ACETA TAB 4.08-325
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
BENZHY/ACETA TAB 6.12-325
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
BENZHY/ACETA TAB 8.16-325
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
BUPAP TAB 50-300MG
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting
BUT/APAP/CAF CAP CODEINE
Classification: Not Covered
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting

Last updated 10/02/2023

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