Download HCL and buprenorphine/naloxone combinations PAGE: 1 of 13

MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 1 of 13
REFERENCE NUMBER: MA.PMN.23
REPLACES DOCUMENT:
EFFECTIVE DATE: 09/06
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
IMPORTANT REMINDER
This Clinical Policy has been developed by appropriately experienced and licensed health care
professionals based on a thorough review and consideration of generally accepted standards of
medical practice, peer-reviewed medical literature, government agency/program approval
status, and other indicia of medical necessity.
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The purpose of this Clinical Policy is to provide a guide to medical necessity. Benefit
determinations should be based in all cases on the applicable contract provisions governing
plan benefits (“Benefit Plan Contract”) and applicable state and federal requirements, as well as
applicable plan-level administrative policies and procedures. To the extent there are any
conflicts between this Clinical Policy and the Benefit Plan Contract provisions, the Benefit Plan
Contract provisions will control.
Clinical policies are intended to be reflective of current scientific research and clinical
thinking. This Clinical Policy is not intended to dictate to providers how to practice medicine,
nor does it constitute a contract or guarantee regarding results. Providers are expected to
exercise professional medical judgment in providing the most appropriate care, and are solely
responsible for the medical advice and treatment of members.
Description: Buprenorphine is a partial opioid agonist that binds to the mu ( )
receptor, reinitiating opioid activity in the brain producing less
euphoria than a full opioid agonist but sufficient activity to
suppress withdrawal and cravings.
Naloxone is a potent antagonist at mu-opioid receptors and
produces opiate withdrawal signs and symptoms when
administered parenterally to individuals physically dependent
on opioid agonists. The naloxone component is included to
discourage diversion and misuse. Naloxone has very limited
bioavailability when administered sublingually, as intended. In
the absence of an opioid, the antagonist has no effect.
Buprenorphine/naloxone tablets and film are generally
Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 2 of 13
REFERENCE NUMBER: MA.PMN.23
REPLACES DOCUMENT:
EFFECTIVE DATE: 09/06
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
administered sublingually as a single daily dose in the range of
12 to 16 mg/day of buprenorphine content, when used as
initial maintenance therapy after the induction period.
Maintenance dosing ranges from 4 to 24 mg per day and
depending on the individual. Adjustments in dosage should be
in 1/0.5mg or 4/1mg increments.
Brand:
buprenorphine (Subutex ): 2mg, 8mg sublingual tablets (only
generic iscurrently marketed)
buprenorphine/naloxone (Suboxone ): Brand Film – Suboxone
12/3mg, 8/2mg, 4/1mg, 2/0.5mg; Brand Tablets –
Zubsolv 5.7/1.4mg and 1.4/0.36mg (equivalent to
8/2mg and 2/0.5mg );
Generic Tablets – 8/2mg and 2/0.5mg only
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FDA Labeled
Indications:
Buprenorphine HCL: Treatment of opioid dependence, preferred
for induction, and for treatment of pregnant women with
opioid addiction
Suboxone® , Zubosolv® and Bunavil®: Maintenance treatment of
opioid dependence.
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Criteria for
Approval:
A. Suboxone® film, when used for the treatment of opioid
addiction, does not require prior authorization from
CeltiCare Health. The usual dosing of Suboxone® film
is 16mg buprenorphoine/day, however quantity limits
for Suboxone® film allow for more flexible dosing if
necessary, and are as follows:
Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 3 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
Suboxone® film dose
2-0.05mg
4-1 mg
8-2 mg
12-3 mg
Monthly Quantity Limit
90 per month
90 per month
90 per month
60 per month
B. CeltiCare Health may review members who are treated with
a dose higher than 16mg buprenorphine/day continuously
for more than 6 months, to assure appropriate care is being
delivered as defined by standards set by national
organizations such as SAMHSA. This review may include a
request to review medical records, a peer to peer
conversation, or other means as deemed appropriate by
CeltiCare Health.
C. Requests for other formulations of burprenorphine/naloxone
containing products, including Zubsolv® and Bunavil®, will
require Prior Authorization, with submission of both a
documented intolerance of Suboxone® film AND
documentation regarding why the requested formulation is
unlikely to cause the same intolerance. The review process
documented in Paragraph B above will similarly apply.
D. Buprenorphine HCL (generic for discontinued Subutex® ),
when used for the induction phase of treatment of opioid
addiction, does not require prior authorization from
CeltiCare Health. It is expected that the induction phase of
treatment will not generally last longer than 7 days.
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Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 4 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
E. Buprenorphine HCL (generic for discontinued Subutex® ),
when used for the treatment of opioid addiction in women
who are pregnant, does not require prior authorization from
CeltiCare Health. There will be no quantity limits imposed
on the prescribing of Buprenorphine HCL when used as
described in this section or the above Paragraph D.
F. Requests for any other use of Buprenorphine HCL will
require a Prior Authorization review, and will require
justification of medical necessity as to why it is to be used
in lieu of the preferred Suboxone® film for the treatment of
opioid addiction.
G. In all cases of prescribing, providers are expected to follow
and be able to produce documentation, if requested by
CeltiCare Health, of evidence that:
I.
Member has a diagnosis of opioid dependency
II. Provider has a unique X-DEA number and is not
treating more than the legally allowed number of
buprenorphine utilizing members
III. Member is actively involved in a substance abuse
treatment program at a level commensurate with
their ability to remain sober and stable
IV. Provider has performed an episodic review of member
specific controlled substance utilization through the
Massachusetts Prescription Monitoring Program
V. Urine Drug Testing is performed at appropriate
intervals, and when necessary as directed by the results
of such testing, treatment adjuncts are implemented
such as participation in more frequent Urine Drug
Testing, participation in an escalated drug treatment
program, or other means as supported in medical
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Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 5 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
literature.
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Approval:
No limitation on the duration of use for Suboxone® film
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For use in pregnancy, Buprenorphine HCL will be covered for
up to two months after delivery.
For use in induction, Buprenorphine HCL will be covered for up
to 7 days.
Initial Approval (other than Suboxone film): 4
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months Continued Approval (other than Suboxone
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film): 1 year
Special Instructions
> Patient should not be using CNS depressants including alcohol while on
Suboxone / Subutex .
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> The combination of benzodiazepines and buprenorphine have resulted in
Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 6 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
serious adverse effects, up to and including coma and death. Deaths have
also been reported in association with coadministration of buprenorphine
with other depressants such as alcohol or other CNS depressant drugs.
Patient does not exhibit significant untreated psychiatric comorbidity,
including suicidal ideation.
Induction:
Prior to induction, consider the type of opioid dependence (i.e. long or shortacting opioid), the time since last opioid use, and the degree or level of opioid
dependence. To avoid precipitating withdrawal, undertake induction with
buprenorphine when objective and clear signs of withdrawal are evident.
Induction can normally be accomplished over a period of 1 or 2 days.
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Switching from tablets to film :
Bioavailability of film is slightly greater than that of the 8/1mg and 12/3mg
tablets; therefore dosage may need to be adjusted when switching from tablets
to film.
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Patients taking heroin or other short-acting opioids:
At treatment initiation, administer the dose of buprenorphine at least 4 hours
after the patient last used opioids or, preferably, when early signs of
withdrawal appear.
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Patients taking methadone of other long-acting narcotics:
There is little controlled experience with the transfer of methadone-maintained
patients to buprenorphine. Available evidence suggests that withdrawal
symptoms are possible during induction of buprenorphine treatment.
Withdrawal appears more likely in patients maintained on higher doses of
methadone (more than 30mg) and when the first buprenorphine dose is
administered shortly after the last methadone dose.
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Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes
of benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 7 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
Prescriber Certification:
Most practitioners certified to prescribe Suboxone can be located on-line
at: http://www.buprenorphine.samhsa.gov/bwns locator/index.html However,
a practitioner may choose not to have his/her name listed. Certified prescribers
are identified on their DEA licenses with an additional DEA number starting
with the letter “X”. Licensing information can be obtained from the local DEA
office. Effective July 25, 2005, physicians must include their DATA 2000 waiver
ID number on prescriptions for opioid addiction treatment medications.
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•
•
For reference, the DSM-V-TR criteria for Opiate Abuse and Dependence
follows. Patient meeting 2-3 of the criteria indicate mild substance use
disorder, 4-5 criteria indicate moderate substance use disorder, and 67
indicates severe substance use disorder (APA, 2013).
Diagnostic criteria:
o Continuing to use opioids despite negative personal consequences
o Repeatedly unable to carry out major obligations at
work, school, or home due to opioid use
o Recurrent use of opioids in physically hazardous situations
o Continued use despite persistent or recurring social or
interpersonal problems caused or made worse by opioid use
o Tolerance (marked increase in amount, marked decrease in effect)
o Withdrawal manifesting as either characteristic syndrome or the
substance is used to avoid withdrawal
o Using greater amounts or using over a longer time
period than intended
o Persistent desire or unsuccessful efforts to cut down or
control opioid use
o Spending a lot of time obtaining, using, or recovering from
using opioids
Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 8 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
o Stopping or reducing important social, occupational,
or recreational activities due to opioid use
o Consistent use of opioids despite acknowledgment of persistent or
recurrent physical or psychological difficulties from using opioids
o Craving or a strong desire to use opioids
Patients should undergo a screening process to determine their
diagnosis, severity of illness, and the selection of the appropriate level
of care for rehabilitation counseling. Use of one of the opioid withdrawal
scales (COWS, OOWS, or SOWS) to assess a patient's level of
withdrawal is encouraged. It is best to use a consistent screening tool
for each patient:
o Clinical Opioid Withdrawal Scale (COWS): common instrument
used by clinicians to assess a patient’s opioid withdrawal severity
o Objective Opiate Withdrawal scale (OOWS): contains 13 physically
observable signs, rated present or absent, based on a timed period
of observation of the patient by a rater
o Subjective Opiate Withdrawal Scale (SOWS): 16 symptoms whose
intensity the patient rates on a scale of 0 (not at all) to 4
(extremely)
Tapering and discontinuation from Buprenorphine
Patient may request to be tapered off of Buprenorphine. Relapse rates are
high after discontinuation. Patients should return for maintenance treatment
if cravings develop after withdrawal.
References: 1. Buprenorphine prescribing information. Accessed October,
2013.. http://bidocs.boehringerCentene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 9 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
ingelheim.com/BIWebAccess/ViewServlet.ser?docBase=rene
tnt&folder Path=/Prescribing+Information/PIs/Roxane/
Bupr enorphine+HCl+Sublingual+Tabs/ 10004964
01+Buprenorp hine+HCl+Sublingual+Tabs.pdf
2. Suboxone prescribing information. Accessed October,
2013. http://www.suboxone.com/pdfs/SuboxonePI.pdf
3. Substance Abuse and Mental Health Services
Administration. Clinical Guidelines for the Use of
Buprenorphine in the Treatment of Opioid Addiction.
2004 Printing. Accessed October, 2013
http://buprenorphine.samhsa.gov/Bup Guidelines.pdf
4. Suboxone /Subutex drug monographs. Clinical
Pharmacology. Accessed October, 2013.
Reynaud M , Petit G , Potard D , Courty P . Six
deaths linked to concomitant use of buprenorphine and
benzodiazepines. Addiction. 1998 Sep;93(9):1385-92.
Kintz P . A new series of 13 buprenorphine-related
deaths. Clin Biochem. 2002 Oct;35(7):513-6.
Lai SH , Yao YJ , Lo DS . A survey of buprenorphine related deaths
in Singapore. Forensic Sci Int. 2006 Oct 16;162(1-3):80-6. Epub 2006
Aug 1.
Pirnay S , Borron SW , Giudicelli CP , Tourneau J ,
Baud FJ , Ricordel I . A critical review of the causes of death
among post-mortem toxicological investigations: analysis of 34
buprenorphine-associated and 35 methadone-associated
deaths. Addiction. 2004 Aug; 99(8):978-88.
New Formulations: Suboxone Sublingual Film: The
Pharmacist’s Letter 2011: 27(1):P 270109
"DSM-5 Substance Use Disorder." BupPractice. Clinical
Tools, Inc. Web. http://www.buppractice.com/node/4621.
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Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 10 of 13
REFERENCE NUMBER: MA.PMN.23
REPLACES DOCUMENT:
EFFECTIVE DATE: 09/06
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
29 Sept. 2014.
11. Buprenorphine Outpatient Outcomes Project: can
Suboxone be a viable outpatient option for heroin
addiction?.Journal of Community Hospital Internal
Medicine Perspectives 2014, 4: 22902 http://dx.doi.org/10.3402/jchimp.v4.22902
12. Clinical Opiate Withdrawal Scale (Flowsheet).
Farmington, CT:The National Alliance of Advocates for
Buprenorphine Treatment, Farmington CT. 1999.
http://www.naabt.org/documents/COWS induction flow s
heet.pdf. Accessed September 15, 2014.
13. Ling, W., et al. (2009). Buprenorphine tapering schedule
and illicit opioid use. Addiction 104: 256-265.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150159/
14. Waller, T. and Rumball, D. (2004) Appendix 18: Objective
Opiate Withdrawal Scale (OOWS), in Treating Drinkers and
Drug Users in the Community, Blackwell Science Ltd,
Oxford, UK. doi: 10.1002/9780470693742.app18
15. Handelsman, L., Cochrane, K. J., Aronson, M. J. Ness,
R., Rubinstein K.J., Kanof, P.D. (1987) Two New Rating
Scales for Opiate Withdrawal. American Journal of
Alcohol Abuse, 13, 293-308.
Revision Log
Revision
Pending P&T Committee Review and Approval
Revised item “c” from “Patient followed in a detox program for
duration of treatment” to “Patient will be followed in a drug
abuse counseling program and will undergo drug monitoring for
the duration of treatment”.
Date
02/09
02/09
Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 11 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
Revised item “d” from “Approved for induction and detox for a period
not to exceed 21 days” to “Suboxone (not Subutex ) can be approved
for induction and dose stabilization for a period not to exceed 30
days”.
Revised item “e” from “ maintenance 11herapy will then be approved
for 3 months” to “ maintenance 11herapy will then be approved for
use of Suboxone (not Subutex ) for an initial 3 month period, with
submission of a proposed titration schedule with the objective of
eventual withdrawal. An additional 3 month period can be approved
based on submission of information verifying continued participation
in drug abuse counseling and continued drug monitoring”.
Added the following note after the Criteria for Approval items: Note:
Subutex treatment can be approved during pregnancy. Methadone is
the therapy of choice for treatment of opioid addiction in pregnancy.
Updated Provider Certification information in the Special
Instructions section to reflect current practices.
Updated References in accordance with materials used in
updating the Guideline.
Updated the “FDA Labeled Indications” and “Criteria for
Approval” sections.
Updated reference section to reflect current literature search.
Specified approval timeframes. Removed language for preferred use
of methadone in pregnancy. References updated.
Specified maximum dosing out to one year.
Added random monthly drug screenings to better define
drug monitoring.
Removed language for preferred use of methadone in pregnancy.
Updated Reference section to reflect current literature search
and reference documents.
Added the following note to Special Instructions: Bioavailability of
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02/09
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Centene Medical Policy Statements represent technical documents developed by the
Medical Management Staff. Questions regarding interpretation of these policies for the
purposes of benefit coverage should be directed to a Medical Management Staff person.
02/09
02/09
02/10
02/10
02/11
11/11
11/11
11/11
11/11
11/12
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 12 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
film is slightly greater than that of the tablets; therefore dosing may
need to be adjusted when switching from tablets to film. Added
specific language that outlines when Subutex will be approved.
Updated reference section to reflect current literature search.
Description – separated out the Naloxone information to parallel
the Buprenorphine description information; added a wider range of
possible maintenance dosing from 4-24mg/day.
Brand – included changes in brand and generic
strengths and availability.
Special Instructions – underlined as heading Switching from tablets
to film and separated from the paragraph before it; added 8-12mg
doses to the first sentence as it has not been shown in lower doses.
Added the following into continued approval criteria” Patients who
have met all the initial approval criteria and have had a gap of at least
6 months in therapy will qualify for 1 new 12 month course of
treatment.” This was requested by BHCP
Updated Reference section to reflect current literature search and
reference documents; added date of printing for third reference.
Clarified criteria and approval timeframes.
Removed Prior authorization requirement for use of preferred agent,
Suboxone® film, modified QL for all doses of Suboxone® film, and
removed prescribing/coverage duration limits for Suboxone® film.
Removed Prior authorization requirement for Buprenorphine HCL
when used in pregnant women.
Reviewed and no changes made.
Annual Review, No Changes
11/13
11/13
11/13
11/13
11/13
08/14
08/15
04/16
03/17
POLICY AND PROCEDURE APPROVAL
Pharmacy & Therapeutics Committee:
Approval on file
V.P., Pharmacy Operations:
Approval on file
Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.
MEDICAL NECESSITY GUIDELINE
DOCUMENT NAME: Buprenorphine
DEPARTMENT: Pharmacy
HCL and buprenorphine/naloxone
combinations
PAGE: 13 of 13
REFERENCE NUMBER: MA.PMN.23
EFFECTIVE DATE: 09/06
REPLACES DOCUMENT:
RETIRED:
REVIEWED: 4/16, 03/17
PRODUCT TYPE: Medicaid
REVISED: 02/09, 02/10, 02/11,
11/11, 11/12, 11/13, 08/14,12/14,
8/15
Sr. V.P., Chief Medical Officer:
Approval on file
Centene Medical Policy Statements represent technical documents developed by the Medical
Management Staff. Questions regarding interpretation of these policies for the purposes of
benefit coverage should be directed to a Medical Management Staff person.