Oxycodone hydrochloride tablets — CareFirst (Caremark)

Initial criteria

• Because of risks of addiction, abuse, and misuse with opioids, reserve use for patients for whom alternative treatment options (e.g., non-opioid analgesics or opioid combination products) have not been tolerated or are not expected to be tolerated, or have not provided adequate analgesia or are not expected to provide adequate analgesia.
• Oxycodone hydrochloride, Oxymorphone hydrochloride, Pentazocine and Naloxone, Qdolo, RoxyBond, Tramadol hydrochloride oral solution, and Tramadol hydrochloride tablets should not be used for an extended period unless pain remains severe enough to require an opioid analgesic and alternative treatments continue to be inadequate.
• For patients age ≤ 19 years with potential first fills of immediate-release opioid prescriptions for non-cancer, non-sickle cell, non-hospice, and non-palliative care related pain, limit to a maximum of a 3-day supply per fill up to 7 days of therapy in a 90-day period.
• Initial quantity limit criteria apply if patient ≤ 19 years has filled ≥ 8-day supply of IR or ER opioid within past 90 days; otherwise, prescriptions >3-day supply require PA for additional quantities.