buprenorphine — Blue Cross Blue Shield of Alabama

Initial criteria

• The prescriber has submitted documentation indicating that the benefits of treatment/use of the listed prescription agent(s) outweigh the risk associated with concomitant buprenorphine use (to be reviewed and verified by a pharmacist or physician)
• The patient will NOT be using the requested agent in combination with another buprenorphine or buprenorphine/naloxone agent (including implantable and injectable buprenorphine) for the requested indication
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The prescriber has verified the patient has been through induction and stabilization therapy and is seeking approval for maintenance therapy
• The patient has an active diagnosis of opioid dependence
• ONE of the following: The patient is currently enrolled in an ongoing outpatient drug addiction treatment program/counseling OR The patient has completed 6 months or more of outpatient drug addiction treatment/counseling and the prescriber provides rationale as to why the patient no longer needs to continue
• The prescriber has submitted a current (within 30 days) patient assessment and treatment plan including: medication history review; frequency and results of urine drug screening; informed consent agreement; anticipated duration of therapy and plan for dose taper or documentation of barriers to drug taper
• The patient is not currently taking an opioid agent including tramadol and tapentadol
• The patient is not currently taking other non‑prescription drugs of abuse and/or alcohol
• ONE of the following: The patient is not currently taking other addictive prescription medications (e.g., muscle relaxants, benzodiazepines, sedative/hypnotics) OR the prescriber has submitted documentation indicating that benefits outweigh risks of concomitant buprenorphine use
• The patient continues to be compliant with all elements of the treatment plan (including recovery‑oriented activities, psychotherapy, and/or other psychosocial modalities)
• The prescriber has reviewed the patient’s records in the state’s PDMP
• The patient will NOT be using the requested agent in combination with another buprenorphine or buprenorphine/naloxone agent for the requested indication
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial up to 2 months or duration of pregnancy if less; renewal 6 months or duration of pregnancy if less