Bcbsnc Prior Review/certification Faxback Form
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1BUPRENORPHINE/NALOXONE (Suboxone®
BUPRENORPHINE/NALOXONE (Suboxone , Zubsolv
, Zubsolv )
BUPRENORPHINE (Subutex®)
BUPRENORPHINE (Subutex )
PRIOR REVIEW/CERTIFICATION FAXBACK FORM
PRIOR REVIEW/CERTIFICATION FAXBACK FORM
INCOMPLETE FORMS MAY DELAY PROCESSING
INCOMPLETE FORMS MAY DELAY PROCESSING
ALL NC PROVIDERS MUST PROVIDE THEIR 5
ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT BCBSNC PROVIDER ID# BELOW
DIGIT BCBSNC PROVIDER ID# BELOW
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What are the prescriber’s DEA prefix letters for this prescription?
DEA prefix letters for this prescription?: (ex. AB1234563) _______________________
_______________________
$%
Is the patient 16 years of age or older?
Is the patient 16 years of age or older? ..............................................................................................
..............................
Yes
No
&%
Is the patient abstinent from illicit drug use?
Is the patient abstinent from illicit drug use? ......................................................................................
......................
Yes
No
'%
Is the patient compliant with all elements of the treatment plan (ex. Recovery
compliant with all elements of the treatment plan (ex. Recovery-oriented activities, psychotherapy,
oriented activities, psychotherapy,
(%
and/or psychosocial modalities)?
)? ................................................................................................
.......................................
Yes
No
If Zubsolv is being requested, has the patient tried and failed,
If Zubsolv is being requested, has the patient tried and failed, is intolerant to, or has a contraindication to generic
or has a contraindication to generic
)%
buprenorphine/naloxone SL tablets?
buprenorphine/naloxone SL tablets? ................................................................................................
..................................
Yes
No
If Subutex or generic buprenorphine SL tablets
Subutex or generic buprenorphine SL tablets are being requested, is the patient using this for any of the
are being requested, is the patient using this for any of the
*%
following conditions:
Induction therapy (Coverage is limited to 5 days)
(Coverage is limited to 5 days)
Allergy to naloxone or naltrexone (
llergy to naloxone or naltrexone (ATTACH medical record documentation of allergy
of allergy)
Pregnancy (ATTACH medical record documentation of treatment plan)
medical record documentation of treatment plan)
QUANTITY LIMIT EXCEPTION CRITERIA
QUANTITY LIMIT EXCEPTION CRITERIA ONLY FOR QUANTITIES OVER 3 FILMS OR TABS/ DAY:
FOR QUANTITIES OVER 3 FILMS OR TABS/ DAY:
1. Please explain why the patient requires a higher dose (
Please explain why the patient requires a higher dose (Attach medical record documentation of treatment plan):
medical record documentation of treatment plan):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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For BCBSNC members, fax form to 1
BCBSNC members, fax form to 1-800-795-9403
Last revision
Last revision
08/2013
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