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NC Medicaid Preferred Drug List- Opioid Analgesics and Combination Therapy Daily MME of Common Dosages Prescribed/Dispensed Conversion Factor Butrans® Patch (generic buprenorphine) Embeda® ER Capsule (morphine/naloxone) fentanyl transdermal patch (brand Duragesic®) Kadian® Capsule (generic morphine ER) morphine sulfate ER tablet (generic for MS Contin®) OxyContin® Tablet (generic oxycodone ER) Fentora® Buccal Tablet (generic fentanyl) Medication Name Conversion Factor hydrocodone-acetaminophen solution (generic for Hycet®, Lorcet®, Lortab®, Norco®, Vicodin®) hydrocodone-acetaminophen tablet (generic for Hycet®, Lorcet®, Lortab®, Norco®, Vicodin®) hydrocodone-ibuprofen tablet (generic for Ibudone®, hydromorphone tablet (generic for Dilaudid® Tablet) morphine solution (generic for MSIR®) morphine tablet (generic for MSIR®) oxycodone concentrated solution (generic for Roxicodone® Intensol) oxycodone solution (generic for Roxicodone®) oxycodone tablet (generic for Roxicodone®) oxycodone-acetaminophen capsules (generic for Tylox®) Medication Name Conversion Factor oxycodone-acetaminophen tablets (generic for Xylon® (branded generic for Repraxin®) (generic hydrocodone/ibuprofen) codeine-acetaminophen solution (generic for Tylenol with Codeine®) codeine-acetaminophen tablet (generic for Tylenol tramadol tablet (generic for Ultram®) tramadol-acetaminophen tablet (generic for Ultracet®) *MME/Day = (qty dispensed/days supply X MG of agent in dosage form) X MME conversion factor (MME rounded up to nearest whole number) (CDC Recommends 90 MME/day or below for patient safety -DMA threshold is 120 MME/day hycet or below to avoid PA request submission) Additional MME Calculator References: Washington State Agency Medical Directors: http://www . 2017 (updated hycet gummies hycet suppository dosage form hycet brand name hycet od dose hycet motrin hycet dosage 12 . pdf This document prepared for NC Medicaid hycet dosage child mg hycet side effects dogs hycet headache hycet baby hycet limit hycet without by CCNC Pharmacy Services 8 . htm CDC hycet dosage effects hycet nursing hycet bleeding hycet blood thinner hycet-cod #3 hycet ndc hycet MME Calculation Guidance: https://www .
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