CurrentArizona Complete HealthPolicy N/A

Substance Abuse Block Grant (SABG) Medication List - English (PDF)

Lists medications covered under the Arizona Complete Health - Complete Care Plan SABG program for opioid, benzodiazepine, and alcohol use disorders, including doses, limitations (e.g., prior authorization), site restrictions, and quantity limits for select agents and supportive treatments.

Policy Summary

PayerArizona Complete Health

PolicySubstance Abuse Block Grant (SABG) Medication List - English (PDF)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required for Buprenorphine SL Tablet and Sublocade; include specified pregnancy ICD-10 codes on prescriptions when Buprenorphine SL Tablet is used for pregnancy supervision; methadone is only available at OTP providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

3Primary disorder categories listed (opioid, benzodiazepine, alcohol)

≥20Medications and supportive treatments listed

2Medications with explicit prior authorization noted

1Agents site-restricted to OTP

The Substance Abuse Block Grant (SABG) medication list identifies medications deemed clinically appropriate for treatment of opioid, benzodiazepine, and alcohol use disorders under the Arizona Complete Health – Complete Care Plan (AzCH-CCP) program. The list includes primary medications, specific formulations and doses, and supportive treatments used for symptom management and related care.

Coverage stance is mixed: many agents and supportive treatments are included with specified doses and some quantity limits, while select medications have explicit limitations such as prior authorization requirements or site restrictions (e.g., methadone available only at OTP).

General Coverage / Limitations

Coverage and limitations for listed SABG medications and supporting treatments:

ALL of the following

Medications listed are included for opioid, benzodiazepine and alcohol use disorders; for other substance use disorders contact the AzCH-CCP Pharmacy Department at 1-888-788-4408 ext 6031278.
Prior authorization exceptions
- Buprenorphine SL Tablet: Prior authorization is required unless the member is pregnant or a postpartum nursing mother.
- Buprenorphine SL Tablet: When prescribing for pregnancy-related supervision, prescriber must note specific ICD-10 codes on the prescription (see Required ICD-10 codes).
- Sublocade: Prior authorization is required.
Site-restricted agents
- Methadone HCL: Only available at an Opioid Treatment Program (OTP) provider.

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Buprenorphine SL Tablet — Authorization Conditions

Buprenorphine SL Tablet Authorization Conditions

Coverage requires meeting ALL of the following unless member is pregnant/postpartum nursing mother:

Prior authorization is required for Buprenorphine SL Tablet unless the member is pregnant or a postpartum nursing mother.

Required ICD-10 codes (examples listed)

O09.91 - Supervision of high-risk pregnancy, 1st Trimester
O09.92 - Supervision of high-risk pregnancy, 2nd Trimester
O09.93 - Supervision of high-risk pregnancy, 3rd Trimester

Applicable Codes

Covered medications and formulations (listed with doses/strengths)mixedCovered

Acamprosate Calcium DR Tablet	DOSE = 333mg
Disulfiram Tablet	DOSE = 250mg, 500mg
Naltrexone HCL Tablet	DOSE = 50mg
Vivitrol IM Suspension	DOSE = 380mg
Clonazepam	DOSE = 0.5mg, 1.0mg, 2.0mg
Phenobarbital	DOSE = 30mg, 60mg
Buprenorphine/Naloxone HCl SL Tablets	DOSE = 2mg/0.5mg, 8mg/2mg
Buprenorphine SL Tablet	DOSE = 2mg, 8mg
Sublocade	DOSE = 100mg/0.5ml, 300mg/1.5ml
Methadone HCL	Site restriction: Only available at an Opioid Treatment Program (OTP) provider

1–10 of 25

1/3

Surface thresholds and quantity limits

Ondansetron HCL Tablets - strength4 mg

Ondansetron HCL Tablets - quantity limitQL: 45

Provider Actions & Requirements

Prior Authorization

Prior authorization required for Buprenorphine SL Tablet (except pregnancy/postpartum nursing)

Prior authorization is required for Buprenorphine SL Tablet unless the member is pregnant or a postpartum nursing mother. When used for pregnancy supervision the prescriber must include the specified pregnancy ICD-10 codes on the prescription.

Prescriptive exception: no prior authorization required if member is pregnant or a postpartum nursing mother.

Prior Authorization

Prior authorization required for Sublocade

Prior authorization is required for Sublocade. Affected formulations: 100mg/0.5ml and 300mg/1.5ml.

Formulations: 100mg/0.5ml
Formulations: 300mg/1.5ml

Documentation Required

Pregnancy ICD-10 codes required on prescription for pregnancy-related buprenorphine use

When Buprenorphine SL Tablet is prescribed for pregnancy supervision, the prescriber must note ICD-10 codes on the prescription. Examples: O09.91 (Supervision of high-risk pregnancy, 1st Trimester), O09.92 (2nd Trimester), O09.93 (3rd Trimester). Ensure the first character is the letter 'O' and the second character is the numeral zero '0'.

Required/example ICD-10 codes: O09.91, O09.92, O09.93
Note: The first digit of the diagnosis code is the letter O (not zero) and the second digit is zero (0).

Documentation Required

Methadone HCL OTP site restriction

Methadone HCL is only available when dispensed at an Opioid Treatment Program (OTP) provider.

OTP = Opioid Treatment Program (definition from policy definitions).

Background

The SABG medication list is intended to document medications and formulations considered appropriate for treatment of substance use disorders (opioid, benzodiazepine, alcohol) and to note coverage limitations and requirements. It includes primary medications and formulations with dosing (e.g., Acamprosate DR 333mg; Disulfiram 250mg/500mg; Naltrexone 50mg; Vivitrol 380mg; Buprenorphine products; Sublocade 100mg/0.5ml and 300mg/1.5ml), supportive medications for symptom management (e.g., clonidine, gabapentin, ondansetron), and quantity limits where specified (e.g., Ondansetron QL: 45).

The list also records specific limitations and documentation requirements—examples include prior authorization for Buprenorphine SL Tablet (except for pregnant or postpartum nursing mothers) and for Sublocade, required ICD-10 pregnancy supervision codes on prescriptions when applicable, and a site restriction for Methadone HCL to Opioid Treatment Program (OTP) providers. For questions about treatment of other substance use disorders or assistance, contact the AzCH-CCP Pharmacy Department at 1-888-788-4408 ext 6031278.

Definitions

OTPOpioid Treatment Program