Opioid Antitussive Quantity Limits
Effective January 1, 2019, HMSA will be placing quantity limits on opioid antitussive products to ensure member safety and appropriate use. Quantity limits are based on product labeling, FDA guidance, standards of medical practice, evidence-based drug information, and published guidelines. These quantity limits will apply to HMSA Commercial formularies (Select, Choice, Essential, Metallic and Optimal) and QUEST Integration.
ALL opioid antitussives will have an Age Limit of 18 year or older.
| Medication | Strength | Quantity Limit |
|---|---|---|
| hydrocodone bitartrate/guaifenesin tab | 5-400 mg | 6 tablets/day |
| hydrocodone w/ homatropine tab | 5-1.5 mg | 6 tablets/day |
| hydrocodone w/ homatropine syrup | 5-1.5 mg/5ml | 30 ml/day |
| codeine polist-chlorphen polist er susp (Tuzistra Xr) | 14.7-2.8 mg/5ml | 20 ml/day |
| chlorpheniramine w/ codeine liquid (Codar Ar ) | 2-8 mg/5ml | 60 ml/day |
| chlorpheniramine w/ codeine liquid (Z-Tuss Ac) | 2-9 mg/5ml | 60 ml/day |
| promethazine w/ codeine syrup | 6.25-10 mg/5ml | 30 ml/day |
| hydrocod polst-chlorphen polst cap er (Tussicaps) | 12hr 5-4 mg | 2 capsules/day |
| hydrocod polst-chlorphen polst cap er (Tussicaps) | 12hr 10-8 mg | 2 capsules/day |
| hydrocod polst-chlorphen polst er susp | 10-8 mg/5ml | 10 ml/day |
| codeine-pyrilamine syrup (Pro-Clear Ac) | 9-8.33 mg/5ml | 60 ml/day |
| promethazine-phenylephrine-codeine syrup | 6.25-5-10 mg/5ml | 30 ml/day |
| phenylephrine-bromphen w/ codeine liquid (M-End Pe ) | 3.33-1.33-6.33 mg/5ml | 90 ml/day |
| phenylephrine-chlorphen w/ codeine syrup (Capcof ) | 5-2-10 mg/5ml | 60 ml/day |
| pseudoephedrine-bromphen-codeine liquid (Rydex) | 10-1.33-6.33 mg/5ml | 90 ml/day |
| pseudoephedrine-bromphen-codeine liquid (Mar-Cof Bp ) | 30-2-7.5 mg/5ml | 60 ml/day |
| pseudoeph-chlorphen w/ hydrocodone soln | 60-4-5 mg/5ml | 30 ml/day |
* This is a list of quantity limits for reference regarding opioid antitussive medications. It does not imply it is a formulary agent. Refer to applicable formulary document for formulary status.
Opioid Quantity Limits
Effective July 1, 2018, HMSA will be placing quantity limits on ALL opioid products to ensure member safety and appropriate use. Quantity limits are based on product labeling, FDA guidance, standards of medical practice, evidence-based drug information, and published guidelines. Quantity limits will not be placed on drugs used for medication-assisted treatment. The following quantity limits are new or are changing effective July 1, 2018. Additional quantity limits and a link to a comprehensive list of quantity limits for opioids will be included in the May 2018 edition of Health Pro News. These limits will apply to ALL HMSA Commercial formularies.
| Medication | Strength | Quantity Limit |
|---|---|---|
| ascomp/cod cap 30mg | 50-325-40-30 mg | 12 capsules per day |
| aspirin-caffeine-dihydrocodeine cap | 356.4-30-16 mg | 336 capsules per month |
| butalbital-acetaminophen tab | 50-300 mg | 12 tablets per day |
| butalbital-acetaminophen tab | 50-325 mg | 12 tablets per day |
| butalbital-acetaminophen-caffeine cap | 50-300-40 mg | 13 capsules per day |
| butalbital-acetaminophen-caffeine cap | 50-325-40 mg | 12 capsules per day |
| butalbital-acetaminophen-caffeine tab | 50-325-40 mg | 12 tablets per day |
| butalbital-acetaminophen-caffeine w/ codeine cap | 50-300-40-30mg | 13 capsules per day |
| butalbital-acetaminophen-caffeine w/ codeine cap | 50-325-40-30 mg | 12 capsules per day |
| butalbital-aspirin-caffeine cap | 50-325-40 mg | 12 capsules per day |
| butalbital-aspirin-caffeine w/ codeine | 50-325-40-30 mg | 12 capsules per day |
| butorphanol tartrate spray | 10mg/ml (2.5ml) | 2 bottles per month |
| codeine sulfate | 15 mg | 24 tablets per day |
| codeine sulfate | 30 mg | 12 tablets per day |
| codeine sulfate | 60 mg | 6 tablets per day |
| fentanyl td (Duragesic) | All strengths | 1 patch every 3 days |
| hydrocodone- acetaminophen (Hycet Soln) | 7.5-325 mg per 15ml | 184 ml per day |
| hydrocodone- acetaminophen (Lortab Elixir) | 10-300 mg per 15ml | 67.5 ml per day |
| hydrocodone- acetaminophen (Norco) | 10-325 mg | 369 tablets per month |
| hydrocodone- acetaminophen (Norco) | 5-325 mg | 369 tablets per month |
| hydrocodone- acetaminophen (Norco) | 7.5-325 mg | 369 tablets per month |
| hydrocodone- acetaminophen (Xodol) | 5-300mg | 12 tablets per day |
| hydrocodone- acetaminophen (Xodol) | 7.5-300 mg | 6 tablets per day |
| hydrocodone- acetaminophen (Xodol) | 10-300 mg | 6 tablets per day |
| hydrocodone bitartrate Er (Zohydro ER) | 10 mg | 4 capsules per day |
| hydrocodone bitartrate Er (Zohydro ER) | 15 mg | 4 capsules per day |
| hydrocodone bitartrate Er (Zohydro ER) | 20 mg | 4 capsules per day |
| hydrocodone bitartrate Er (Zohydro ER) | 30 mg | 2 capsules per day |
| hydrocodone bitartrate Er (Zohydro ER) | 40 mg | 2 capsules per day |
| hydrocodone bitartrate Er (Zohydro ER) | 50 mg | 2 capsules per day |
| hydrocodone bitartrate ER (Hysingla ER) | All strengths | 1 tablet per day |
| hydrocodone-ibuprofen | All strengths | 6 tablets per day |
| hydromorphone ER | All strengths | 1 tablet per day |
| hydromorphone hcl supp | 3 mg | 4 suppositories per day |
| hydromorphone hcl tabs | 2 mg | 12 tablets per day |
| hydromorphone hcl tabs | 4 mg | 6 tablets per day |
| hydromorphone hcl tabs | 8 mg | 6 tablets per day |
| levorphanol | 2 mg | 120 tablets per month |
| meperidine hcl | 50mg | 24 tablets per month |
| meperidine hcl | 100 mg | 12 tablets per month |
| morphine sulfate beads cap ER | All strengths | 1 capsule per day |
| morphine sulfate ER | All strengths | 3 tablets per day |
| morphine sulfate soln | 10 mg/5ml | 1800 ml per month |
| morphine sulfate soln | 2 0mg/5ml | 900 ml per month |
| morphine sulfate soln | 100 mg/5ml | 180 ml per month |
| morphine sulfate tablet | 15 mg | 180 tablets per month |
| morphine sulfate tablet | 30 mg | 180 tablets per month |
| opium tincture deodorized | 10mg/ml | 120 ml per month |
| oxycodone hcl | 5 mg | 360 tablets per month |
| oxycodone hcl | 10 mg | 180 tablets per month |
| oxycodone hcl | 15 mg | 180 tablets per month |
| oxycodone hcl | 20 mg | 180 tablets per month |
| oxycodone hcl | 30 mg | 180 tablets per month |
| oxycodone hcl tab ER 12hr deter | All strengths | 3 tablets per day |
| oxymorphone ER (Opana ER) | All strengths | 4 tablets per day |
| oxymorphone hcl | 5 mg | 360 tablets per month |
| oxymorphone hcl | 10 mg | 360 tablets per month |
| oxymorphone hcl ER | All strengths | 2 tablets per day |
| pentazocine/naloxone | 50 mg/0.5mg | 360 tablets per month |
| tapentadol (Nucynta) | 50 mg | 12 tablets per day |
| tapentadol (Nucynta) | 75 mg | 8 tablets per day |
| tapentadol (Nucynta) | 100 mg | 6 tablets per day |
| tapentadol ER (Nucynta ER) | 50 mg | 10 tablets per day |
| tapentadol ER (Nucynta ER) | 100 mg | 5 tablets day |
| tapentadol ER (Nucynta ER) | 150 mg | 3 tablets per day |
| tapentadol ER (Nucynta ER) | 200 mg | 2 tablets per day |
| tapentadol ER (Nucynta ER) | 250 mg | 2 tablets per day |
| tramadol hcl | 50 mg | 240 tablets per month |
| tramadol hcl ER cap | 100 mg | 3 tablets per day |
| tramadol hcl ER cap | 150 mg | 2 tablets per day |
| tramadol hcl ER cap | 200 mg | 2 tablets per day |
| tramadol hcl ER cap | 300 mg | 1 tablet per day |
| tramadol hcl ER tab | 100 mg | 3 tablets per day |
| tramadol hcl ER tab | 200 mg | 2 tablets per day |
| tramadol hcl ER tab | 300 mg | 1 tablet per day |
| tramadol/acetaminophen | 37.5-325 mg | 40 tablets per month |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |