CurrentArizona Complete HealthPolicy N/A

SABG Medication List for Substance Use Disorders

Lists medications included on the Arizona Complete Health Substance Abuse Block Grant (SABG) formulary for treatment of opioid, benzodiazepine, and alcohol use disorders and related supportive treatments; informs prescribers and pharmacy regarding available agents and noted limitations/authorization requirements.

Policy Summary

PayerArizona Complete Health

PolicySABG Medication List for Substance Use Disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for Buprenorphine SL Tablet and Sublocade when required, and include specified ICD-10 pregnancy supervision codes on prescriptions to exempt pregnant or postpartum nursing mothers from PA for buprenorphine.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~30medications and formulations listed

Some productsPA required

OTP onlyMethadone dispensing

IncludedNaloxone

Formulary and Coverage Notes

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Formulary inclusion and specific limitations

Medications listed are included on the SABG formulary; some products have specific limitations or authorization requirements as noted below.

Formulary inclusion: Listed medications (e.g., acamprosate, disulfiram, naltrexone, buprenorphine (SL and buprenorphine/naloxone), Sublocade, clonazepam, phenobarbital, methadone, naloxone, and supportive agents such as carbamazepine, clonidine, gabapentin, trazodone) are part of the SABG medication list.

See individual limitations and PA requirements

PA exceptions: Buprenorphine SL Tablet requires prior authorization except when the member is pregnant or a postpartum nursing mother and the prescriber includes the specified ICD-10 pregnancy supervision codes on the prescription (O09.91, O09.92, O09.93).

Prescriber must document the ICD-10 pregnancy supervision codes on the prescription

Prior authorization required for Sublocade: Sublocade (extended‑release buprenorphine) requires prior authorization.

Dispensing restrictions: Methadone HCL is only available via an Opioid Treatment Program (OTP) provider.

Dispensing setting is restricted to OTPs

This document lists medications included on the Arizona Complete Health Substance Abuse Block Grant (SABG) formulary for treatment of opioid, benzodiazepine, and alcohol use disorders. It does not provide lists or guidance for treatments of other substance use disorders. For medications or treatment questions outside of opioid, benzodiazepine, and alcohol use disorders, prescribers should contact the AzCH-CCP Pharmacy Department at 1-888-788-4408, extension 6031278.

Medications included on the SABG list may have product-specific limitations or authorization requirements. For example, Buprenorphine SL Tablet requires prior authorization except when prescribed for pregnant or postpartum nursing mothers with the specified ICD-10 pregnancy supervision codes noted on the prescription. See the coverage criteria and provider actions sections for details on prior authorization and required diagnosis coding.

Coding and Dose Details

ICD-10 codes referenced for buprenorphine exceptionICD-10

O09.91	Supervision of high-risk pregnancy, 1st Trimester (as cited for buprenorphine prescription)
O09.92	Supervision of high-risk pregnancy, 2nd Trimester (as cited for buprenorphine prescription)
O09.93	Supervision of high-risk pregnancy, 3rd Trimester (as cited for buprenorphine prescription)

Vivitrol dose

Vivitrol (naltrexone extended-release) dose380 mg (single intramuscular injection)

ContextListed as Vivitrol dose in SABG medication thresholds

Use noteUsed for opioid and alcohol use disorder as part of MAT options on the SABG formulary

Prior Authorization & Prescriber Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain buprenorphine products and for Sublocade. Providers must include required documentation and diagnosis codes for buprenorphine exceptions when requesting an exception for pregnant or postpartum nursing members. Methadone HCL is restricted to dispensing at Opioid Treatment Program (OTP) providers.

Prior authorization required for buprenorphine sublingual tablet except when member is pregnant or a postpartum nursing mother.
When requesting an exception for pregnancy or postpartum nursing mother, the prescriber must include an appropriate pregnancy supervision ICD-10 code on the prescription: O09.91, O09.92, O09.93 (note: the first character is the letter 'O' and the second is the number zero '0').
Prior authorization is required for Sublocade (100mg/0.5ml and 300mg/1.5ml).
Methadone HCL for opioid use disorder is only available through Opioid Treatment Program (OTP) providers — dispensing restriction.

Documentation Required

Provider Action: Required Diagnosis Codes for Buprenorphine Exceptions

Action required: include the pregnancy-related ICD-10 diagnosis code on the prescription when seeking an exception to buprenorphine prior authorization for pregnant or postpartum nursing members. Confirm the code uses the letter 'O' (not zero) as the first character and the second character is the numeral zero.

Accepted codes for pregnancy supervision (examples shown on prescription): 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)

Prior Authorization

Prior Authorization for Sublocade

Prior authorization is required for Sublocade maintenance injections. Submit PA documentation per payer requirements to support medical necessity for Sublocade.

Sublocade DOSE: 100mg/0.5ml and 300mg/1.5ml — PA required.
Include clinical rationale and prior treatment history as requested by Arizona Complete Health when submitting PA for Sublocade.

Billing Rule

OTP Dispensing Restriction for Methadone

Methadone HCL is limited to dispensing at certified Opioid Treatment Program (OTP) providers. Do not dispense methadone for opioid use disorder through retail pharmacy channels.

Methadone HCL dispensing restricted to OTP providers only.
If referring a member for methadone treatment, coordinate with an OTP provider for enrollment and administration.

Key Definitions

SABG Medication list definition

DefinitionSABG Medication list — the formulary of medications supported by Arizona Complete Health-Complete Care Plan (AzCH-CCP) for treatment of opioid, benzodiazepine, and alcohol use disorders.

ScopeIncludes medications with demonstrated clinical safety and efficacy for opioid, benzodiazepine, and alcohol use disorders; prescribers should contact AzCH-CCP Pharmacy for other substance use disorders.

Intended usersPrescribers and pharmacy staff managing SABG-funded treatments within AzCH-CCP.

Opioid Treatment Program (OTP) definition

DefinitionOpioid Treatment Program (OTP) — a certified clinic provider authorized to dispense methadone for opioid use disorder.

Dispensing restrictionMethadone HCL on the SABG list is only available via an OTP provider.

Operational noteMembers requiring methadone must receive treatment and dispensing through an OTP setting per the formulary restriction.