Upmc Health Plan - Suboxone, Zubsolv, & Subutex Page 2
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2UPMC Health Plan
Suboxone, Zubsolv, & Subutex
Page 2
Patient Name
Patient UPMC Health Plan ID Number:
Patient DOB:
st
Please be sure to complete and include this page with the 1
page of this form.
Is the member currently taking a benzodiazepine?
Yes
No
If yes, will there be an attempt to taper off benzodiazepine therapy?
Yes
No
Is this an INITIAL authorization request?
Yes
No
If Yes, please submit the following:
Documentation of an initial evaluation or scheduled appointment by a licensed Drug and Alcohol provider to
determine the recommended level of care.
Documentation of referral to or enrollment in formal behavioral health counseling and/or substance abuse
counseling. Initial treatment must be performed with a licensed Drug and Alcohol or a behavioral health
provider that is consistent with the level of care recommended at the initial authorization.
Documentation enclosed
Documentation not available
Yes
No
Is this a REAUTHORIZATION request?
If Yes, please submit the following:
Documentation showing the member is participating in at least monthly formal behavioral health
counseling, substance abuse counseling, or an addiction recovery program.
Documentation enclosed
Documentation not available
Please complete the following questions for Subutex requests ONLY:
Is the member pregnant?
Yes
No
Does the member have intolerance to naloxone?
Yes
No
If yes, please provide chart documentation describing intolerance.
Documentation enclosed
Documentation not available
Please complete the following questions for Suboxone TABLET requests for UPMC for You members ONLY:
Please submit documentation showing why the member cannot use the Suboxone film or Zubsolv tablet. Please
include clinical information showing an adequate trial of Suboxone film with an inadequate response or
intolerance.
Documentation enclosed
Documentation not available
Please provide clinical rationale to support the need for dose requests exceeding the quantity limit of 60
tablets/film strips per 30 days:
Please provide any additional information which should be considered in the space below:
Suboxone, Zubsolv, Subutex PA form
May 2014
All PA forms available at
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