Upmc Health Plan - Suboxone, Zubsolv, & Subutex
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2UPMC Health Plan
Suboxone, Zubsolv, & Subutex
Prior Authorization Form for UPMC for Life, UPMC for You Advantage, UPMC for Life Options, and
UPMC for Community Care Medicare Members
IF THIS IS AN URGENT REQUEST, please call UPMC Health Plan Pharmacy Services.
Otherwise please return completed form to:
UPMC HEALTH PLAN PHARMACY SERVICES
PHONE: 1-800-979-UPMC (8762)
FAX: 412-454-7722
PLEASE TYPE OR PRINT NEATLY
Incomplete responses may delay this request.
Office Contact:
Provider Specialty:
\
UPMC HEALTH PLAN PHARMACY SERVICES
PHONE 800-979-UPMC (8762)
FAX 412-454-7722
Provider First Name:
Provider Last Name:
Provider Phone:
Provider Fax:
Provider NPI #:
Member Name:
UPMC Health Plan ID Number:
DOB:
Age:
Drug Requested:
Strength:
Frequency:
Qty Dispensed:
2mg
Suboxone film
Subutex tablet
2-0.5mg
8mg
Suboxone tablet
Zubsolv tablet
4-1mg
1.4-0.36mg
8-2mg
Brand
Generic
5.7-1.4mg
12-3mg
Generic equivalent drugs will be substituted for brand-name drugs unless you specifically indicate otherwise.
New medication
If ongoing, provide date
If medication is ongoing, did the member
Yes
Ongoing medication
started:
show improvement while on therapy?
No
Restart
Diagnosis:
Date of diagnosis:
Please complete the following questions for ALL requests
Does the prescribing physician have a unique identification number issued by the
Yes
No
DEA certifying prescribing authority for Subutex?
Please submit documentation of a recent urine drug screen within the last 3 months. Please include date of test. Testing
should include licit and illicit drugs with the potential for abuse and include oxycodone.
Documentation enclosed
Documentation not available
Please provide the names of any controlled substance medications that are currently prescribed to the
member:
Medication Name
Strength/Frequency
Dates of Therapy
For reauthorization requests, please provide clinical rationale to support continuation of therapy if urine drug screen is
positive for opiates and/or negative for Suboxone/Zubsolv/Subutex.
Compliance with Suboxone/Zubsolv/Subutex is required. Pharmacy claims will be reviewed. If applicable, please
provide clinical rationale to support continuation of Suboxone/Zubsolv/Subutex despite apparent noncompliance.
nd
Please be sure to complete and include the 2
page of this form.
Suboxone, Zubsolv, Subutex PA form
May 2014
All PA forms available at
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