Morphine Sulfate (lower strengths available)
Medication
Generic Name
Strength
Quantity Limit
Avinza
Morphine sulfate
30mg, 45mg, 60mg
1 per day
Kadian
Morphine sulfate
10mg, 20mg, 30mg, 40mg, 50mg, 2 per day
60mg, 80mg
MS Contin
Morphine sulfate
15mg, 30mg, 60mg, 100mg
3 per day
Oramorph SR
Morphine sulfate
15mg, 30mg, 60mg, 100mg
3 per day
Morphine Sulfate (highest strength available)
Medication
Generic Name
Strength
Quantity Limit
Avinza
Morphine sulfate
75mg, 90mg, 120mg
2 per day
Kadian
Morphine sulfate
100mg, 200mg
2 per day
MS Contin
Morphine sulfate
200mg
2 per day
OVERRIDE(S)
Prior Authorization of Benefits and/or Quantity Supply
APPROVAL DURATION
1 year
APPROVAL CRITERIA
For approval of increased quantities of morphine sulfate products, the following criteria must be
met:
A.
Requests for increased quantity can be approved for the diagnosis of cancer.
**Note: It may be possible in some instances to use a higher strength of the requested
medication and take fewer tablets/capsules to achieve the same total daily dosage
requested.**
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Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on
behalf of health plan members.