Fillable Printable Buprenorphine Criteria

Buprenorphine Criteria

Douglas A. Ducey, Governor

Thomas J. Betlach, Director

801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 •

602-417-4000 •

www.azahcccs.gov

Buprenorphine Prior Authorization Criteria

Effective Date: July 1, 2016

CRITERIA FOR COVERAGE:

 Member has a diagnosis of opioid dependence, and

 The Prescriber is certified through SAMHSA (Substance Abuse and Mental

Health Services Administration) and provides the registration number, and

 The prescription is part of an overall treatment program, and

 The member is not receiving any other opioids since beginning therapy as

verified by the Arizona State Board of Pharmacy Controlled Substance

Prescription Monitoring Program, and

 The member is pregnant, or intolerant to buprenorphine/naloxone agents.

COVERAGE LIMITATION:

Opioid dependence products are subject to quantity limitations determined by the

maximum bioequivalent amount of buprenorphine allowed per day:

 Buprenorphine 2mg – 12 tablets per day

 Buprenorphine 8mg – 3 tablets per day

REAUTHORIZATION CRITERIA AND DURATION:

Authorization for continued use shall require coverage criteria to be met and confirm

that the prescriber is evaluating random urine drug screens and assessment of the

patient’s progress (e.g., relapse, progress/accomplishment of treatment goals).