buprenorphine sublingual tablets — CareFirst (Caremark)

Initial criteria

• The requested drug is being used as part of a complete program for the treatment of opioid use disorder, which may include behavioral therapies (e.g., individual therapy, group counseling, family behavior therapy, cognitive behavioral therapy, motivational enhancement, motivational incentives, mutual support), medical history, physical exam, and screening laboratory tests as needed (e.g., HIV and hepatitis C screening), diversion control protocols such as observed dosing, pill counts, testing for buprenorphine’s metabolite (nor-buprenorphine), random urine testing for opioids and other illicit substances, and use of the Prescription Drug Monitoring Program (PDMP) if available in state.
• The requested drug is being prescribed for induction therapy and/or subsequent maintenance therapy for the treatment of opioid use disorder AND the patient meets ONE of the following: is pregnant or breastfeeding, has an intolerance to naloxone, or has moderate or severe liver impairment.
• OR the requested drug is being prescribed for induction therapy for transition from opioid use to treatment of opioid use disorder.

Approval duration

Induction therapy: 3 months; Induction and/or maintenance in pregnancy, naloxone intolerance, or moderate/severe liver impairment: 12 months