CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Request for Prior Authorization - Opioid with Concurrent Buprenorphine/Naloxone or Buprenorphine

Form and instructions governing prior authorization requests when prescribing an opioid concurrently with buprenorphine/naloxone or buprenorphine for members served by Anthem Blue Cross and Blue Shield programs listed; applies to prescribing providers completing the PA form.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyRequest for Prior Authorization - Opioid with Concurrent Buprenorphine/Naloxone or Buprenorphine

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form in its entirety and fax to the Prior Authorization of Benefits Center using the listed numbers; mark the box for retroactive PA and provide dates when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7default max days

844-864-7860retail fax

888-209-7838injectable fax

All sections requiredincomplete forms

Coverage Criteria

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Coverage criteria for concurrent opioid use

Covered when ALL of the following are met:

Opioid (opiate) therapy prescribed is seven days or less unless an explanation is provided for a longer duration.

If opioid therapy is expected to exceed seven days, provide a brief explanation including expected duration and a taper/discontinuation plan.

Prior authorization form completed in its entirety by the prescribing provider; all sections must be completed or the request will be returned.

Submit the completed form by fax to the Prior Authorization of Benefits Center using the appropriate number (844-864-7860 for retail or 888-209-7838 for medical injectable). Mark the retroactive PA box and provide dates of service when applicable.

Provider Actions and Submission Instructions

Prior Authorization

Submission instructions and retroactive PA

Complete the prior authorization form in its entirety and fax to the Prior Authorization of Benefits Center at 844-864-7860 for retail submissions or 888-209-7838 for medical injectable submissions. Mark the box on the form if requesting a retroactive prior authorization and provide the dates of service when applicable; submit retroactive requests with dates of service prior to 30 calendar days of submission separately from current PA requests.

Retail fax: 844-864-7860
Medical injectable fax: 888-209-7838
If requesting retroactive PA, mark the box and list date(s) of service
Submit retroactive DOS prior to 30 calendar days separately from current requests

Documentation Required

Concurrent therapy approval and justification

Confirm the prescriber of buprenorphine/naloxone or buprenorphine has been notified and approves the use of the prescribed opioid therapy, and indicate the buprenorphine prescriber's name on the form. If opioid therapy is expected to continue concomitantly for greater than seven days, provide a brief explanation including expected duration and a taper/discontinuation plan.

Document prescriber's name approving concurrent therapy
Provide explanation and taper plan if therapy > 7 days

Denial Risk

Form completion requirement

All sections of the PA form must be completed by the prescribing provider; incomplete forms will be returned.

Form must be completed by the prescribing provider
All sections required — requests with missing information will be returned

Definitions

Definition: Concurrent opioid/buprenorphine PA

Form name/definitionConcurrent opioid/buprenorphine PA form: the specific prior authorization request used when opioids are prescribed concomitantly with buprenorphine or buprenorphine/naloxone.

Duration conditionForm captures whether opioid therapy is seven days or less; if greater than seven days an explanation and taper/discontinuation plan must be provided.

ApplicabilityUsed for prior authorization requests across Anthem Blue Cross and Blue Shield programs listed on the form (e.g., Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging).