Prior Authorization Request Form - Suboxone Renewal Page 2

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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:

Q8. Is there a patient treatment contract in place? Must attach a signed patient copy.



Yes



Q9. Does the patient treatment contract include consequences of violating the rules of the contract?



Yes

Q10. Is there documentation of continued 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

Q11. Is the name, location and counseling schedule attached?



Yes



Q12. Does the patient have a co-occurring mental health disorder?



Yes



Q13. If the patient has been diagnosed with a co-occurring mental health disorder, is the patient continuing to receive

treatment for that condition? Please provide documentation of treatment.



Yes

Q14. Has the patient been treated with Suboxone® film strips for greater than 12 months?



Yes



Q15. Has an assessment of clinical effectiveness and dose (including an evaluation for a dose decrease) been

conducted? Please attach documentation.



Yes



Q16. Is the urine drug screen negative for opioids opioids (including oxycodone and fentanyl), benzodiazepines, skeletal

muscle relaxants, tramadol, CNS stimulants, and illicit drugs?



Yes



Q17. Is there a documented plan attached to address the findings of the urine drug screen?



Yes

Q18. Does the patient's prescription profile show concurrent fills for opioids, benzodiazepines and/or skeletal muscle

relaxants and Suboxone while the patient's urine drug screen is negative for opiods, benzodiazepines and/or skeletal

muscle relaxants, and Suboxone?



Yes



Q19. Has the patient demonstrated compliance with Suboxone therapy as evidenced by a positive urine drug screen for

both buprenorphine and norbuprenorphine? Please submit all urine drug screen results collected since the previous

approval.



Yes



Q20. Is the dose less than or equal to 24 mg/day?

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