Bcbs Suboxone Physician Prior Authorization Request Form printable pdf download

Bcbs Suboxone Physician Prior Authorization Request Form

UBOXONE

HYSICIAN

RIOR

UTHORIZATION

EQUEST

ORM

BlueCross

BlueShield

of South Carolina

Patient Information

Name:

Insurance ID #:

Address:

Birthdate:

Provider Information

Physician’s Name:

Physician DEA #:

Phone:

Fax:

Office Address:

Diagnosis:

ICD-9 Code:

When this form is complete, please fax to Caremark at 866-692-2630.

This fax machine is in a HIPAA-compliant, secure location. On behalf of BlueCross BlueShield of South Carolina, Caremark assists in the

administration of prescription drug programs. Caremark is an independent company that provides pharmacy benefits management.

Call Caremark at 800-294-5979 with any questions concerning prior authorization procedures.

1. Is the patient greater than or equal to 16 years of age?

2. Does the patient have the diagnosis of opioid dependence?

3. Is the physician prescribing the drug for induction phase?

4. Will the daily dose exceed 32 mg per day?

5. Is the prescriber certified through SAMHSA (Substance Abuse and Mental Health Services

Administration) to prescribe Suboxone and Subutex?

[If the answer to this question is yes, what is the registration number?]

6. Is the prescriber treating more than 100 patients at a given time?

Confidential

Page 1 of 2

Revised: 01/26/2010

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

Bcbs Suboxone Physician Prior Authorization Request Form