butalbital/aspirin/caffeine/codeine capsules — Blue Cross Blue Shield of Alabama

Initial criteria

• - Opioid naïve patients limited to ≤7 days initial immediate-release opioid duration
• - Continuation allowed when not opioid naïve
• - Requests for therapy >7 days in patients without opioid use in past 180 days require prior authorization for extended therapy
• - Age ≥12 years for tramadol, dihydrocodeine, or codeine products
• - Patients aged 12–18 years restricted from use after tonsillectomy and/or adenoidectomy
• - If total morphine equivalent dose ≥210 mg, prescriber must acknowledge risk and provide treatment plan to reduce MED or rationale why reduction not possible
• - Maximum daily dose and age limits apply per product list

Reauthorization criteria

• - Confirmation patient is not opioid naïve
• - Reassessment of pain control and risk mitigation per CDC guideline
• - Prescriber acknowledges risks and provides plan for any dose ≥210 mg MED

Approval duration

7 days initial limit; extended duration requires PA