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Fillable Printable Buprenorphine Criteria

Fillable Printable Buprenorphine Criteria

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 CRITERIAAND 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).
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