Oxycontin 80Mg(OC80)&40Mg(OP40) Loose Pills

Price range: $500 through $700

This policy involves the use of oxycodone ER (Oxycontin) 80 mg. Prior authorization is recommended for pharmacy benefit
coverage of oxycodone ER (Oxycontin) 80 mg. Conditions Not Recommended for Approval are listed following the
recommended authorization criteria. Some members may also be subject to the long acting opioid step therapy.

Requests for uses not listed in this policy will be reviewed for evidence of efficacy and for medical necessity on a caseby
case basis.

Translate »