Us Script Suboxone/subutex Opioid Detoxification Prior Authorization Request Form printable pdf download

SUBOXONE/SUBUTEX OPIOID DETOXIFICATION

PRIOR AUTHORIZATION REQUEST FORM

This completed form may be FAXED TO 1-866-399-0929* Requests for prior authorization (PA) requests must include member name, ID#,

and drug name. Incomplete forms will delay processing.

A 72-hour supply of medication may be requested by phoning 1-800-460-8988.

Request may be mailed to: US Script PA Dept. / 2425 West Shaw Avenue / Fresno, CA 93711

US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays.

For immediate response on weekends and holidays, NurseWise will answer your call.

II. Member Information

I. Provider Information

Prescriber name (print):

Member Name:

Office Contact Name:

ID#:

Fax:

Date of Birth:

Phone:

Medication allergies:

III General Information – (Please complete for both Suboxone and Subutex requests).

Drug name and strength – Circle One

Dose:

Dosage Interval (sig):

Qty per Day:

Suboxone

Subutex

Diagnosis relevant to this request/ICD-9 code:

Data 2000 Waiver ID (“X” DEA Number):

Opioid Dependence – 304.0

Expected length of therapy:

Documentation that outlines the clinical evaluation and the opioid dependence treatment plan must be provided with the

initial request for Suboxone that includes the proposed titration schedule from starting dose to drug free status.

Is the Member Pregnant? (Circle One):

Yes

If Yes, please state the estimated delivery date:

Is the patient allergic to Naloxone? (Circle One):

Yes

If “No” was not selected for one of the questions above and Subutex is being requested, please provide the clinical

rationale for prescribing Subutex instead of Suboxone in the space below:

IV: Renewal Information - (Please complete ONLY for Renewal Requests).

Please check off all clinical rationale for the renewal of Suboxone/Subutex and provide supportive documentation that supports its

clinical necessity:

⁭ Consistent use of Suboxone/Subutex since the initial authorization was granted (note: if gaps of therapy are apparent in the

pharmacy claims database, an explanation as to why these gaps are present will be required).

⁭ Continued participation in drug abuse counseling (attach relevant documentation to confirm such enrollment).

⁭ Monthly negative urine tests for opiates since authorization (attach all monthly urine drug screens since the initial

authorization was granted).

V: Approval and Renewal Criteria

Suboxone® (not Subutex®) can be approved for induction and dose stabilization for a period not to exceed 30 days. An additional

3 month period can be approved based on submission of information verifying continued participation in drug abuse

counseling and continued drug monitoring. Subutex® treatment can be approved during pregnancy. Methadone is the therapy of

choice for treatment of opioid addiction in pregnancy.

Do not use this form for pain management.

Prescriber must be

certified to prescribe Suboxone and manage opioid dependence and be issued a Data 2000 Waiver ID number (“X” DEA

number).

Documentation that outlines the clinical evaluation and the opioid dependence treatment plan that includes the

proposed titration schedule down to drug free must be provided with the initial request for Suboxone.

VI. ADDITIONAL PERTINENT CLINICAL INFORMATION / RATIONALE FOR REQUEST:

Provider Signature:

Date:

Us Script Suboxone/subutex Opioid Detoxification Prior Authorization Request Form

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