Suboxone (Brand Only) — United Healthcare

Preferred products

• buprenorphine/naloxone (generic Suboxone)
• Zubsolv

Initial criteria

• Patient is being treated for opioid dependence
• AND BOTH of the following:
• One of the following:
• - Submission of medical records documenting an inadequate response to a minimum 30-day trial of Zubsolv (trial must be completed prior to PA request)
• - OR Submission of medical records documenting adverse effects or contraindication to Zubsolv including manifestation or reason for contraindication
• AND One of the following:
• - Submission of medical records documenting an inadequate response to a minimum 30-day trial of buprenorphine/naloxone (generic Suboxone) (trial must be completed prior to PA request)
• - OR Submission of medical records documenting adverse effects or contraindication to buprenorphine/naloxone (generic Suboxone) including manifestation or reason for contraindication

Reauthorization criteria

• Documentation of positive clinical response

Approval duration

12 months