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buprenorphine - naloxone

Drugs
buprenorphine with naloxone, Suboxone®(CIII)
Dose Forms: 

  • sublingual tablets 
  • sublingual film and buccal film 

buprenorphine, Subutex
Dose Forms: sublingual tablets, brand and generic

January 2015

Therapeutic area - Drugs for opiate dependency, mu receptor opioid agonist

The prescriber should document that they actively review the patient’s drug profile on the Prescription Drug Monitoring database.  

Buprenorphine/naloxone sublingual film (Preferred) 

Approval criteria

  • The prescription written is for a patient who has been diagnosed with opiate dependency and the medication is intended for use as detoxification or maintenance of opiate dependency AND
  • The physician prescribing is authorized by the Drug Enforcement Agency (DEA) to prescribe medications for opiate dependent individuals as evidenced by a DEA registration AND
  • No more than two active PA’s are allowed at one time. Two strengths may be used at one time, allowing for some dosage titration, but no more than 24 mg per day is allowed.

Buprenorphine/naloxone sublingual tablets (Nonpreferred) 

Approval criteria

  • The prescription written is for a patient who has been diagnosed with opiate dependency and the medication is intended for use as detoxification or maintenance of opiate dependency AND
  • The physician prescribing is authorized by the Drug Enforcement Agency (DEA) to prescribe medications for opiate dependent individuals as evidenced by a DEA registration AND
  • Provider provides clinical documentation that the film cannot be used AND
  • No more than two active PA’s are allowed at one time. Two strengths may be used at one time, allowing for some dosage titration, but no more than 24 mg per day is allowed.

Subutex or buprenorphine generic

Buprenorphine is the preferred drug for induction. 

Approval criteria

  • A patient who has been diagnosed with opiate dependency and the medication is intended for use as induction detoxification of opiate dependency AND
  • The physician prescribing is authorized by the Drug Enforcement Agency (DEA) to prescribe medications for opiate dependent individuals as evidenced by a DEA registration number AND
  • If being used for long term therapy, the patient has shown a clear intolerance to naloxone AND
  • Only one active PA is allowed at one time and therefore, only one strength per patient and only one dosage form per patient is allowed simultaneously

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

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