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Buprenorphine with naloxone and Buprenorphine

October 2018

Therapeutic area - Opiate Dependence Treatment

Drugs

Preferred

  • Suboxone film

Nonpreferred

  • Bunavail
  • buprenorphine tablet
  • buprenorphine with naloxone film
  • buprenorphine with naloxone tablet
  • Zubsolv

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

Preferred Drug: Suboxone film

  • No prior authorization is required
  • Quantity limits apply

Nonpreferred Drugs: Bunavail, buprenorphine with naloxone film, buprenorphine with naloxone tablet, Zubsolv

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 PAs are allowed at one time. Two strengths may be approved at one time, allowing for some dosage titration. Quantity limits apply.  

Nonpreferred Drug: buprenorphine tablet

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. Two strengths may be approved at one time, allowing for some dosage titration. Quantity limits apply.  

Quantity Limits

Drug Quantity limit per 34 days
Bunavail 2.1-0.3 mg film 68
Bunavail 4.2-0.7 mg film 68
Bunavail 6.3-1 mg film 68
Buprenorphine 2mg sublingual tablet 136
Buprenorphine 8mg sublingual tablet 102
Buprenorphine-naloxone 2mg-0.5mg sublingual tablet 136
Buprenorphine-naloxone 8mg-2mg sublingual tablet 102
Buprenorphine-naloxone 8mg-2mg film 102
Suboxone 2mg-0.5mg film 102
Suboxone 4mg-1mg film 102
Suboxone 8mg-2mg film 102
Suboxone 12mg-3mg film 68
Zubsolv 0.7-0.18mg sublingual tablet 68
Zubsolv 14-0.36mg sublingual tablet 68
Zubsolv 2.9-0.71mg sublingual tablet 68
Zubsolv 5.7-1.4mg sublingual tablet 68
Zubsolv 8.6-2.1mg sublingual tablet 68
Zubsolv 11.4-2.9mg sublingual tablet 34

Questions?

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

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