CurrentBlue Cross Blue Shield - AlabamaPolicy N/A

Buprenorphine and Buprenorphine/Naloxone Prior Authorization Request Form

This document is a prior authorization request form governing authorization of prescription drug benefits for buprenorphine products (including combination with naloxone) for Blue Cross Blue Shield - Alabama members; it specifies information and documentation the prescriber must provide for induction, stabilization, and maintenance therapy.

Policy Summary

PayerBlue Cross Blue Shield - Alabama

PolicyBuprenorphine and Buprenorphine/Naloxone Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the form with the treatment-specific section and submit required supporting documentation (treatment plan, urine drug screen, medication history, DATA 2000 waiver).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3form sections

fax/mailsubmission methods

waiverDATA 2000 waiver captured

drug screensupporting doc requested

Coverage Criteria

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Induction/Stabilization

Induction/Stabilization authorization — Covered when ALL of the following are met

Induction criteria: Prescriber maintains current informed consent signed by the prescriber and patient; prescriber has verified that the patient is not currently taking or will discontinue use of opioid medication and/or other addictive drugs (including problematic alcohol and/or benzodiazepine use) prior to beginning treatment with the requested agent; prescriber attests that the patient is enrolled in an ongoing outpatient drug addiction treatment/counseling program or will seek enrollment within the first 2 months of treatment; prescriber has attached an initial treatment plan including a current baseline urine drug screen and documentation of medication history review; supportive documentation and clinical chart notes are provided for review.

Maintenance Therapy

Maintenance therapy authorization — Covered when ALL of the following are met

Maintenance criteria: Prescriber maintains current informed consent signed by the prescriber and patient; prescriber certifies they meet DATA requirements and have not exceeded the maximum number of patients allowed; patient completed induction/stabilization for confirmed active opioid dependence and consistent use of the requested agent since prior authorization will be verified prior to approval; prescriber has submitted a current treatment plan including a medication history review and the most recent drug screen showing the patient is free from illicit drug use; prescriber has reviewed the state's prescription drug monitoring program (PDMP) to confirm no diversion; patient remains enrolled in and compliant with outpatient drug addiction treatment/counseling or a rationale is provided for discontinuation; documentation of anticipated duration of treatment, plan for drug taper, or barriers to taper is provided; supportive documentation and clinical chart notes are provided for review.

No specific exclusions are listed on the form. The document’s treatment sections and instructions do not enumerate any explicit conditions or diagnoses that are categorically excluded from consideration.

The form does not present a standalone Not Medically Necessary (NMN) list. Implicitly, authorization would not be approved when the required documentation or criteria for the chosen treatment phase are not met—for example, missing the signed informed consent, lack of baseline or recent urine drug screen, absent initial or current treatment plan, failure to document enrollment in outpatient addiction counseling (or a rationale), or failure to meet DATA 2000 provider limits and requirements where applicable. These documentation and criteria deficiencies are the practical reasons an authorization would be denied.

Provider Actions & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization requires completion and submission of the signed, treatment-specific prior authorization form and all requested supporting documentation. Do not submit incomplete forms — missing sections may delay review or result in denial.

Complete the entire prior authorization form, including Section I (Treatment Information) and the appropriate Section II (Induction/Stabilization) or Section III (Maintenance) depending on the request type.
Signed prescriber and patient informed consent must be attached for induction, stabilization, and maintenance requests.
Fax completed form to Pharmacy Review: 1-866-606-6021 or mail to Pharmacy Review, Post Office Box 529, Auburn, AL 36381.

Documentation Required

Product Selection Justification

When requesting buprenorphine monotherapy (e.g., Subutex) instead of buprenorphine/naloxone (e.g., Suboxone), the prescriber must justify the product selection in the form. Common acceptable justifications include pregnancy or a documented allergic reaction or intolerance to naloxone. If naloxone intolerance is claimed, provide medical records documenting the reaction.

For Subutex requests: indicate whether the member is pregnant and provide anticipated delivery date if yes.
If naloxone intolerance or allergy is the reason for buprenorphine alone, attach medical records documenting the reaction.
If neither pregnancy nor naloxone intolerance applies, provide a clear medical necessity explanation for choosing buprenorphine monotherapy over buprenorphine/naloxone.

Documentation Required

Required Documentation

Attach all required documentation with the prior authorization submission. Incomplete documentation may result in denial or delay of the request.

Initial treatment plan (for induction/stabilization) or current treatment plan (for maintenance) including anticipated duration of treatment and plan for taper or justification for continued maintenance.
Baseline and/or most recent urine drug screen demonstrating current status (induction: baseline; maintenance: most recent showing abstinence from illicit drugs).
Medication history review and documentation of current/past opioid or controlled substance use and any recent prescription monitoring program (PDMP) review.
Clinical chart notes supporting medical necessity, including verification of enrollment or plan to enroll in outpatient addiction treatment/counseling, informed consent, and verification that patient is not currently taking or will discontinue other opioids prior to initiation.

Denial Risk

Missing Documentation / Denial Risk

Failure to attach required supportive documentation (treatment plan, urine drug screen, medication history, clinical notes, PDMP review, informed consent, and naloxone-allergy records when applicable) may lead to denial of the authorization request. Ensure all requested sections of the form are completed and documents are legible.

Missing initial treatment plan, urine drug screen, or medication history review increases risk of denial for induction/stabilization requests.
Missing most recent drug screen, PDMP review, or treatment plan increases risk of denial for maintenance requests.
Unclear or missing product-selection justification for buprenorphine monotherapy (e.g., absence of pregnancy documentation or naloxone-allergy records) may result in denial or request for additional information.

Background

This prior authorization form is used to request coverage for medication-assisted treatment (MAT) with buprenorphine products and captures the information needed to determine authorization for either induction/stabilization or maintenance therapy. The form records the requested product and dose, the prescriber’s DATA 2000 waiver ID ('X' DEA number), the patient’s diagnosis code, and treatment-phase specific attestations (see separate induction and maintenance sections). For induction/stabilization requests the prescriber must attest to informed consent, verify discontinuation of other opioids/addictive drugs, document enrollment or plan to enroll in outpatient addiction treatment within two months, and attach an initial treatment plan with a baseline urine drug screen and medication history review. For maintenance requests the prescriber must attest to continued informed consent, meet DATA requirements, document that the patient completed induction/stabilization and has consistent use of the requested agent, submit a current treatment plan with the most recent drug screen free from illicit drugs, confirm PDMP review, document continued enrollment and compliance in outpatient addiction treatment (or provide a rationale), and provide anticipated duration or taper plan. The form also asks prescribers to justify use of buprenorphine alone (Subutex) versus buprenorphine/naloxone when applicable and to provide supporting medical records for naloxone allergy or pregnancy-related requests. Submission instructions (fax or mail) are provided on the form.

OpenPayer

Buprenorphine and Buprenorphine/Naloxone Prior Authorization Request Form

Coverage Criteria

Coding

Provider Actions & Documentation

Level of Care

Treatment Modalities

Definitions

Background