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Pain Medications (Combination Products) Quantity Limit Program Summary

Policy Number: PH-1192

This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace.

POLICY REVIEW CYCLE                                                                                                                                                                           

Effective Date

Date of Origin 

04-01-2024            

FDA APPROVED INDICATIONS AND DOSAGE

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

QL Amount

Dose Form

Day Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

Butalbital-Acetaminophen Cap 50-300 MG

50-300 MG

180

Capsules

30

DAYS

Butalbital-Aspirin-Caffeine Cap 50-325-40 MG

50-325-40 MG

180

Capsules

30

DAYS

Allzital

Butalbital-Acetaminophen Tab 25-325 MG

25 MG ; 25-325 MG

360

Tablets

30

DAYS

Bac ; Esgic

Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG

50-325-40 MG

180

Tablets

30

DAYS

Bupap

Butalbital-Acetaminophen Tab 50-300 MG

50-300 MG

180

Tablets

30

DAYS

Esgic ; Zebutal

Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG

50-325-40 MG

180

Capsules

30

DAYS

Fioricet

Butalbital-Acetaminophen-Caffeine Cap 50-300-40 MG

50-300-40 MG

180

Capsules

30

DAYS

Tencon

Butalbital-Acetaminophen Tab 50-325 MG

50-325 MG

180

Tablets

30

DAYS

Vtol lq

Butalbital-Acetaminophen-Caffeine Soln 50-325-40 MG/15ML

50-325-40 MG/15ML

2700

mLs

30

DAYS

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Butalbital-Acetaminophen Cap 50-300 MG

50-300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Butalbital-Aspirin-Caffeine Cap 50-325-40 MG

50-325-40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Allzital

Butalbital-Acetaminophen Tab 25-325 MG

25 MG ; 25-325 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Bac ; Esgic

Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG

50-325-40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Bupap

Butalbital-Acetaminophen Tab 50-300 MG

50-300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Esgic ; Zebutal

Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG

50-325-40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fioricet

Butalbital-Acetaminophen-Caffeine Cap 50-300-40 MG

50-300-40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tencon

Butalbital-Acetaminophen Tab 50-325 MG

50-325 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vtol lq

Butalbital-Acetaminophen-Caffeine Soln 50-325-40 MG/15ML

50-325-40 MG/15ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) exceeds the program quantity limit AND BOTH of the following:
    1. ONE of the following:
      1. BOTH of the following:
        1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
        2. Information has been provided to support therapy with a higher dose for the requested indication OR
      2. BOTH of the following:
        1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
        2. Information has been provided to support why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
      3. BOTH of the following:
        1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
        2. Information has been provided to support therapy with a higher dose for the requested indication AND
    2. If the requested agent contains acetaminophen, the daily dose of acetaminophen does NOT exceed over 4 grams per 24 hours

Length of Approval: Approval duration is 1 month for dose titration requests and up to 6 months for all other requests 

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

 

 

 

Commercial _ PS _ Pain_Medications_QL _ProgSum_ 04-01-2024