Prior Authorization Request Form - Suboxone
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3HEALTH PARTNERS PLANS
PRIOR AUTHORIZATION REQUEST FORM
SUBOXONE®
Phone: 215-991-4300
Fax back to: 866-240-3712
Health Partners Plans manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician.
Please answer the following questions and fax this form to the number listed above.
PLEASE NOTE: Any information (patient, prescriber, drug, labs) left blank, illegible, or not attached WILL delay the review process.
Patient Name:
Prescriber Name:
Member Number:
Fax:
Phone:
Date of Birth:
Office Contact:
Address:
NPI:
State Lic ID:
City, State ZIP:
Address:
Primary Phone:
City, State ZIP:
Line of Business: □ Healthy PA Medicaid
□ Healthy PA PCO
□ CHIP
Specialty/facility name (if applicable):
□ Expedited/Urgent
Drug Name:
Strength:
Directions / SIG:
1
Please attach any pertinent medical history including labs and information for this member that may support approval.
Please answer the following questions and sign.
Q1. What is the duration of the therapy requested?
1 month or less
More than 1 month
Q2. Is the request for film strips?
Yes
No
Q3. What is the age of the patient?
Less than 16 years
16 years or greater
Q4. If the patient is female, is she negative for pregnancy?
Yes
No
Male
Q5. Is the physician certified to prescribe Suboxone® / Subutex® for office-based treatment of opioid dependence (is in
accordance with DATA 2000, previously notified the Substance Abuse and Mental Health Services Administration
(SAMHSA) of their intent to treat patients with Suboxone® / Subutex® and was issued a special DEA number)?
Yes
No
Q6. Has the patient signed a consent form authorizing the certified physician to release the patient’s medical information
in the patient record for the purposes of referral to substance abuse or behavioral health treatment? Please attach copy
of consent form.
Yes
No
Q7. Has the patient been formally diagnosed with opioid use dependence according to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)? Please attach documentation (chart notes with
DSM criteria and/or Suboxone® and Subutex® Appropriate use Checklist).
Yes
No
This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or
entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are
hereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy in
error, please notify the sender immediately to arrange for the return of this document
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