Medication Assisted Treatment (MAT) Criteria
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Defines prior authorization, formulary status, clinical criteria, and coverage duration for buprenorphine-, naloxone-, and naltrexone-based MAT products for members aged 16 and older. Affects prescribers and pharmacy benefit prior authorization reviewers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Sublocade (buprenorphine extended-release) coverage criteria
Covered when ALL of the following are met
Probuphine (buprenorphine implant) coverage criteria
Covered when ALL of the following are met
Buprenorphine HCL sublingual tablet exceptions
Covered when ANY of the following are met
All Other Non-Formulary MAT drugs
Covered when ANY of the following are met
Medical Director/clinical reviewer may override when they judge the item medically necessary.
Formulary status identifies products covered at point of sale and those that are non‑formulary requiring prior authorization. Formulary, pays at point of sale items include buprenorphine HCL/naloxone HCL sublingual tablets (Suboxone film) and Vivitrol (naltrexone microspheres) injectable. Products listed as Non‑Formulary, Requires Prior Authorization include buprenorphine HCL sublingual tablets, Probuphine (buprenorphine implant), Sublocade (buprenorphine syringe), Bunavail buccal film, Zubsolv sublingual tablet, and any other newly marketed agents in this class. When criteria are met, approvals may be granted for up to 12 months.
Requests that do not meet the product‑specific coverage criteria or that lack required clinical documentation may be referred for clinical review and may be determined not medically necessary. Examples of required documentation include diagnosis, prior medication trials or failures (for non‑formulary agents), and evidence of required buprenorphine exposure or stability (for example, lead‑in dosing or duration where applicable). Absent this documentation or failure to satisfy the stated prerequisites, prior authorization requests are at risk for denial by the clinical reviewer.
Coding and Dosing Requirements
Provider Actions and Documentation
Prior authorization required for non‑formulary MAT agents
Prior authorization is required for non-formulary MAT agents and approval may be granted up to 12 months when criteria are met. Affected products listed as non‑formulary include buprenorphine HCL sublingual tablets, Probuphine (buprenorphine implant), Sublocade (buprenorphine syringe), Bunavail, Zubsolv, and other non‑formulary or newly marketed agents in this class.
- If criteria are met, requests approved for up to 12 months.
- Formulary status section lists specific non‑formulary products that require prior authorization.
Step therapy: trial/failure of buprenorphine HCL/naloxone sublingual tablets
For 'All Other Non‑Formulary Drugs' the member must have a documented trial and failure of buprenorphine HCL/naloxone HCL sublingual tablets, or have a documented medical reason (allergy, intolerance, hypersensitivity, or contraindication) for not using that product; the Medical Director/clinical reviewer may override when they judge the item medically necessary.
- Step therapy requires trial and failure of buprenorphine HCL/naloxone sublingual tablets prior to approval of other non‑formulary MAT agents.
- Documented medical reasons to bypass step therapy include allergy, intolerance, hypersensitivity, or contraindication.
Required clinical documentation to support prior authorization requests
Provide clinical documentation that supports the diagnosis and required prior trials or stability (e.g., trial and failure of buprenorphine/naloxone for non‑formulary drugs; 8–24 mg/day buprenorphine for ≥7 days prior to Sublocade; ≥6 months stability on ≤8 mg/day for Probuphine). Include pregnancy status if applicable and any medical reasons for contraindications to naloxone.
- Document buprenorphine dose and duration (e.g., 8–24 mg/day ≥7 days for Sublocade).
- Document stability on ≤8 mg/day for ≥6 months for Probuphine and completion of required insertion training for the inserter.
- If seeking non‑formulary agent, document trial/failure of buprenorphine/naloxone or medical justification (e.g., allergy, pregnancy plan).
Requests not meeting criteria will be referred to clinical review and may be denied
Requests that do not meet the listed criteria or lack required documentation will be referred to a clinical reviewer for medical necessity review and may be denied; the Medical Director/clinical reviewer may override criteria when they judge the item medically necessary.
- Non‑formulary requests without required trials, stability, or documentation subject to referral and potential denial.
- Clinical reviewer/Medical Director may override based on professional judgment.
Treatment Modalities
MAT
Definitions
Background
Medication‑assisted treatment (MAT) for opioid use disorder uses buprenorphine‑based and naltrexone‑based products to reduce opioid use and related harms. The policy addresses formulary status and authorization requirements for multiple MAT modalities, including transmucosal buprenorphine formulations, long‑acting injectable buprenorphine (Sublocade), subdermal buprenorphine implants (Probuphine), and injectable naltrexone (Vivitrol). Specific long‑acting formulations have prerequisites to ensure safe initiation: for example, Sublocade requires prior oral/transmucosal buprenorphine at 8–24 mg/day for at least 7 days with no supplemental buprenorphine, and Probuphine is intended only for members maintained on ≤8 mg/day buprenorphine with clinical stability on the same dose for ≥6 months. These requirements are intended to align use with product labeling and to support appropriate patient selection.
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