Prior Authorization Request Form - Suboxone Renewal

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HEALTH PARTNERS PLANS

PRIOR AUTHORIZATION REQUEST FORM

SUBOXONE® Renewal

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:

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:

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?



3 months or less

More than 3 months

Q2. Has the patient been previously approved for Suboxone?



Yes



Q3. Is the member pregnant?



Yes



Male

Q4. Is the physician certified to prescribe Suboxone for office-based treatment of opiod 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, and was issued a special DEA number?



Yes

Q5. Is there documentation of referral to or participation in a substance abuse or behavioral health (BH) treatment

program, BH counseling, or an addictions recovery program? During the initial course of treatment, referral and

enrollment must be with a licensed Drug and Alcohol (D&A) or BH provider. Documentation must be attached.



Yes

Q6. Is this a different prescriber than the prescriber in the initial request?



Yes



Q7. 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



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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