Opiate Combinations
Drug - Opiate combinations with acetaminophen or ibuprofen
December 2018
Generic products containing 325mg APAP are preferred products
| Brand name |
Generic ingredients |
Strengths |
| Maxidone |
Hydrocodone/Acetaminophen |
10/750 mg |
| Vicodin |
Hydrocodone/Acetaminophen |
5/300 mg, 7.5/300 mg, 10/300mg |
| Xodol |
Hydrocodone/Acetaminophen |
7.5/300 mg |
| Nalocet |
Oxycodone/Acetaminophen |
2.5/300 mg |
| Primlev |
Oxycodone/Acetaminophen |
5/300 mg, 7.5/300 mg, 10/300 mg |
| Ibudone |
Hydrocodone/Ibuprofen |
5/200 mg, 10/200 mg |
| Reprexain |
Hydrocodone/Ibuprofen |
2.5/200 mg, 5/200 mg, 7.5/200 mg, 10/200 mg |
| Vicoprofen |
Hydrocodone/Ibuprofen |
7.5/200 mg |
| Xylon |
Hydrocodone/Ibuprofen |
10/200 mg |
| Combunox |
Oxycodone/Ibuprofen |
5/400 mg |
Approval criteria for Maxidone, Vicodin, Xodol (hydrocodone/acetaminophen) and Nalocet, Primlev (oxycodone/acetaminophen)
- Patient is being treated for moderate to moderately severe pain AND
- Patient has an adequate adherent trial and failure of generic oxycodone/acetaminophen products (e.g., generic product with 325 mg APAP) AND
- Patient has an adequate adherent trial and failure of generic hydrocodone/acetaminophen products (e.g., generic product with 325 mg APAP) AND
- Prescriber has a reason why a combination product must be used
Approval criteria for Combunox (oxycodone/ibuprofen) and Ibudone, Reprexain, Vicoprofen and Xylon (generic hydrocodone/ibuprofen)
- Patient is greater than:
- 16 years for a hydrocodone/ibuprofen product OR
- 14 years for an oxycodone/ibuprofen product AND
- Patient is being treated for acute or moderate-to-severe pain AND
- Patient has an adequate adherent trial and failure of ibuprofen plus any immediate release opioid analgesic used concomitantly AND
- Prescriber has a reason why a combination product must be used
Quantity Limits
Limit on Days’ Supply of the First Opioid Prescription
The first opioid prescription, based on Fee-for-Service Medicaid’s prescription claim history of 90 days, will be limited to no more than 7-day supply.
Authorization may be granted for first opioid prescription’s 7-day limit override if:
- Correct calculated day supply per prescriber direction is verified AND
- The member has a diagnosis of cancer OR
- The member is currently undergoing palliative care and NOT hospice care OR
- The request is for a retro-eligibility claim OR
- The request is for a TPL claim where the TPL paid for over 60% of the allowable amount OR
- The member has a medically necessary travel plan OR
- The request is for a bridge of service
Authorization may NOT be granted for 7-day limit override if:
- The member does NOT have a medically necessary travel plan
- A follow-up appointment can be made before 7-day supply is depleted
Daily Limit of Opioid Prescriptions
Opioid prescriptions are limited to a maximum dose of 90 morphine equivalents per day (MED). Opioid prescriptions written for doses greater than 90 MED require prior authorization. To request prior authorization, the following forms must be completed and faxed to MHCP Prescription Drug PA Review Agent:
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411
