Nc Dma Preferred Drug List - Opioid Analgesics And Combination Therapy Page 3

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Medication Name
Mg Strength
DMA/NCTracks
Qty
Days Supply
MME per day*
MME Conversion
Dispensed
Factor
oxycodone-acetaminophen tablets (generic for
5/325
1.5
40
5
60
Percocet®)
10/325
40
5
120
Xylon® (branded generic for Repraxin®) (generic
10/200
1
40
5
80
hydrocodone/ibuprofen)
120
30
40
codeine-acetaminophen solution (generic for
36/360-15ml
0.15
240ml
4
22
Tylenol with Codeine®)
(2.4mg/ml
473ml
10
17
Codeine)
codeine-acetaminophen tablet (generic for Tylenol
30/300 (#3)
0.15
40
10
18
with Codeine®)
60/300 (#4)
40
10
36
tramadol tablet (generic for Ultram®)
50mg
0.1
40
5
40
tramadol-acetaminophen tablet (generic for Ultracet)
37.5/325
0.1
40
5
30
*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 or below to avoid PA request submission)
Additional MME Calculator References:
Washington State Agency Medical Directors:
CDC MME Calculation Guidance:
https://
This document prepared for NC Division of Medical Assistance by CCNC Pharmacy Services 8.16.2017
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