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UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM

SUBOXONE, ZUBSOLV, BUNAVAIL

(buprenorphine/naloxone)

Please see separate criteria for buprenorphine single-agent oral products

Patient name:___________________________________Medicaid ID #:_______________________________

Prescriber Name:_________________Prescriber NPI#:_______________Contact person:__________________

Prescriber Phone#:___________________Extension/Option:________________Fax#:____________________

Pharmacy:______________________Pharmacy Phone#:____________________Fax #:___________________

Pharmacy NPI:____________________Strength:________________Frequency/Day:_____________________

All information to be legible, complete and correct or form will be returned

________________________________________________________________________________________

FAX DOCUMENTATION FROM PROGRESS NOTES

855-828-4992

AND THIS COMPLETED FORM TO

If the prescriber desires to provide additional information or detail, a letter of medical necessity

will be accepted as a supplement to, but not a replacement for, progress notes.

INITIAL CRITERIA:



Minimum age requirement: 16 years old



Documented diagnosis of opioid dependence



Prescribing physician must provide their X-DEA number:_________________________



Evidence supplied of plans for on-going treatment monitoring that includes drug urine screening, or DOPL

reports, or random pill counts



Description of the psychosocial support to be received by patient, as indicated by chart notes or a brief

letter of medical necessity



A treatment plan that includes a tapering plan and discontinuation of pharmacotherapy



No concomitant therapy with Vivitrol (naltrexone)



No concomitant therapy with opiate analgesics

AUTHORIZATION:

Initial 18-month authorization at a maximum of 24mg-6mg/day (Suboxone), 17.1mg-4.2mg/day (Zubsolv) or 12.6mg-

2.1mg/day (Bunavail).

RE-AUTHORIZATION:

Re-authorization period is 18-months at a maximum dose of 24mg-6mg/day (Suboxone), 17.1mg-4.2mg/day (Zubsolv) or

12.6mg-2.1mg/day (Bunavail) if the following criteria are met:



Letter of explanation detailing why an additional approval is needed



Evidence of psychosocial support received by patient



Evidence that a taper plan has been attempted, and if failed, why



Detailed plans for immediate taper if initial taper failed



A negative urine screen completed within 14 days of reauthorization start date



No concomitant therapy with Vivitrol (naltrexone)



No concomitant therapy with opiate analgesics

NOTE: Treatment will only be covered up to 36 months (18 month initial authorization and 18 month re-

authorization).

NDC CHANGES: NDC changes for dosage tapering must be submitted in an updated letter of medical necessity,

faxed to 855-828-4992

04/10/2015

Prior Authorization Request Form (Suboxone, Zubsolv, Bunavail) - Utah Department Of Health

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