CurrentNeighborhood Health Plan of Rhode IslandPolicy 2328-HJ

Buprenorphine Sublingual Tablets — Coverage Criteria for Opioid Use Disorder

This document governs pharmacy coverage limits and prior authorization criteria for buprenorphine sublingual tablets for treatment of opioid use disorder for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBuprenorphine Sublingual Tablets — Coverage Criteria for Opioid Use Disorder

Policy CodePolicy 2328-HJ

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for requests that exceed initial quantity limits or a cumulative 30-day supply within the past 3 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 mg: 901 month initial limit

8 mg: 1201 month initial limit

12 moapproval period

30-dayduration limit trigger

Coverage Criteria for Buprenorphine Sublingual Tablets

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Drug Coding and Quantity Limits

Covered drug namesNDCCovered

buprenorphine

Generic name; sublingual tablets (all dosage forms and strengths unless otherwise stated)

Initial monthly tablet limits

2 mg — initial monthly quantity90 tablets per 25 days (equivalent to 3 tablets/day)

8 mg — initial monthly quantity120 tablets per 25 days (equivalent to 4 tablets/day)

Duration used for fill period25 days is used to represent a 30-day fill period for initial limits

3-month supply limits (post-PA)

2 mg — 3-month cumulative quantity270 tablets per 75 days (equivalent to 3 tablets/day)

8 mg — 3-month cumulative quantity360 tablets per 75 days (equivalent to 4 tablets/day)

Duration/PA triggerIf requesting more than a cumulative 30-day supply within the past 3 months, the claim will reject and require prior authorization

Provider Actions, Prior Authorization, and Documentation

Denial Risk

Quantity limit and duration overage rejection

If the patient is requesting more than the initial quantity limit, the claim will reject with a message indicating that a prior authorization is required. The prior authorization criteria would then be applied to requests submitted for evaluation to the PA unit.

Limits do not accumulate together; patient is allowed the maximum limit for each drug and strength.

Note

None specified

No specific provider action is specified beyond the standard prior authorization process and documentation requirements described elsewhere in this section.

Prior Authorization

Prior authorization required for over-limit or specific clinical indications

If the patient is requesting more than a cumulative 30-day supply within the past 3 months, the claim will reject with a message indicating that a prior authorization is required. The prior authorization criteria would then be applied to requests submitted for evaluation to the PA unit.

buprenorphine sublingual tablets, Duration Limit (per 3 months) = 30-day supply

Documentation Required

Required clinical documentation for prior authorization

Authorization may be granted when the requested drug is being prescribed for induction therapy and/or subsequent maintenance therapy for the treatment of opioid use disorder when ONE of the following criteria is met: patient is pregnant or breastfeeding; patient has an intolerance to naloxone; patient has moderate or severe liver impairment. Documentation is required for approval in each of these situations.

Pregnancy or breastfeeding — ACTION REQUIRED: Documentation required for approval.
Intolerance to naloxone — ACTION REQUIRED: Documentation required for approval.
Moderate or severe liver impairment — ACTION REQUIRED: Documentation required for approval.

Definitions

Buprenorphine Sublingual Tablets

DefinitionBuprenorphine Sublingual Tablets: medication indicated for the treatment of opioid dependence and preferred for induction as part of a complete treatment plan including counseling and psychosocial support.

IndicationTreatment of opioid dependence (used for induction and maintenance of opioid use disorder)

Care integrationShould be used as part of a comprehensive treatment plan including counseling and psychosocial support

Induction/Maintenance

InductionInitiation of buprenorphine therapy to transition a patient onto medication for opioid use disorder (start of treatment).

MaintenanceOngoing buprenorphine therapy after induction to sustain treatment of opioid use disorder.

Documentation noteAuthorization for induction or maintenance may require documentation when patient is pregnant, breastfeeding, intolerant to naloxone, or has moderate/severe liver impairment.

Background

Buprenorphine sublingual tablets are an FDA‑approved medication for the treatment of opioid dependence and are the preferred formulation for induction therapy. Use of buprenorphine sublingual tablets should occur as part of a comprehensive treatment plan that includes counseling and psychosocial support. Authorization may be granted when these tablets are prescribed for induction and/or maintenance of opioid use disorder and when one of the policy’s clinical approval conditions is met (for example, pregnancy or breastfeeding, intolerance to naloxone, or moderate to severe liver impairment); documentation is required for approval in those circumstances.