Subutex (Buprenorphine Hcl) Prior Authorization Of Benefits (Pab) Form
ADVERTISEMENT
1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
®
Subutex
(buprenorphine HCl)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: __________________________________
Prescribing Physician: ____________________________
Patient ID #:
__________________________________
Physician Address:
_____________________________
Patient DOB: __________________________________
Physician Phone #:
_____________________________
Date of Rx:
__________________________________
Physician Fax #:
_____________________________
Patient Phone #: _______________________________
Physician Specialty:
____________________________
Patient Email Address: ___________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY
®
□
□
Subutex
(buprenorphine HCl)
______________________
______________________
2mg
8mg
7. DIAGNOSIS: ______________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
Initial Therapy:
Prescribers DEA number: ______________________
Prescribers unique DATA 2000 waiver identification number (that is, X DEA number): __________________
□
□
®
Yes
No
Subutex
(buprenorphine HCl) is being used for opioid use disorder
□
□
Yes
No
Patient and prescriber have a formal written agreement regarding treatment for opioid use disorder
□
□
Yes
No
Patient is participating in a comprehensive rehabilitation program (consisting of either inpatient or
outpatient services) that includes psychosocial support provided by a program counselor qualified by
education, training, or experience to assess the patients psychological and sociological background
□
□
Yes
No
Patient is pregnant
□
□
Yes
No
Patient has a documented allergic reaction to Suboxone (hypersensitivity to naloxone component)
□
□
®
Yes
No
Subutex
(buprenorphine HCl) is being used in combination with any of the following medications:
opioid agents; sedative/hypnotic agents (including non-benzodiazepine hypnotics and phenobarbital
containing agents; or benzodiazepine agents
□
□
Yes
No
Written documentation* from the prescriber has been provided with this request
of buprenorphine regarding medical necessity and evidence that the patient has
been counseled on the risk of concomitant use
□
□
Yes
No
Patient is 16 years of age or older
*Documentation may include, but is not limited to, chart notes, prescription claims records, prescription
receipts, and laboratory data.
PAGE 1 OF 2
CONTINUED ON PAGE 2
Subutex NTL PAB Fax Form 12.15.15.doc
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business