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    Buprenorphine with naloxone and Buprenorphine

    April 2019

    Therapeutic area - Opiate Dependence Treatment

    Drugs

    Preferred

    • Suboxone film
    • buprenorphine with naloxone tablet

    Nonpreferred

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

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

    Preferred Drug: Suboxone film, buprenorphine with naloxone tablet

    • No prior authorization is required
    • Quantity limits apply

    Nonpreferred Drugs: Bunavail, buprenorphine with naloxone film, 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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