CurrentUnitedHealthcarePolicy N/A

Opioid Use Disorder treatments prior authorization

This form governs prior authorization requests for opioid use disorder (OUD) pharmacologic treatments and related quantity/daily dose limits for UnitedHealthcare members under the DHS pharmacy program in Pennsylvania. It affects prescribers and pharmacies submitting PA prior authorization requests.

Policy Summary

PayerUnitedHealthcare

PolicyOpioid Use Disorder treatments prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed prior authorization form and required clinical documentation to DHS - Pharmacy Division at 1-866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PAjurisdiction

1-866-940-7328fax number

1-800-310-6826PA Call Center

Availablenaloxone access

Coverage Criteria for Opioid Use Disorder Treatments

Initial Authorization Criteria

Covered when documentation shows all applicable items are satisfied

Non-preferred sublingual buprenorphine: For a non-preferred SUBLINGUAL buprenorphine product (eg, film, tablet): documentation the patient tried and failed or has a contraindication or intolerance to the preferred SUBLINGUAL buprenorphine Opioid Use Disorder treatments.N/A

Refer to https://papdl.com/preferred-drug-list for a list of preferred and non-preferred agents.

Non-preferred non-sublingual buprenorphine: For a non-preferred NON-SUBLINGUAL buprenorphine product (eg, injection): documentation the patient tried and failed or has a contraindication or intolerance to the preferred NON-SUBLINGUAL buprenorphine Opioid Use Disorder treatments.N/A

Refer to https://papdl.com/preferred-drug-list for a list of preferred and non-preferred agents.

Policy Summary

PayerUnitedHealthcare

PolicyOpioid Use Disorder treatments prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed prior authorization form and required clinical documentation to DHS - Pharmacy Division at 1-866-940-7328.

SourceLink

On This Page

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Provider Actions, Submission & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-preferred Opioid Use Disorder (OUD) treatments. Providers must submit the completed OPIOID USE DISORDER TREATMENTS PRIOR AUTHORIZATION FORM with supporting clinical documentation (see checklist) to the Medicaid pharmacy prior authorization fax line.

Fax completed form and required clinical documentation to DHS - Pharmacy Division.
Include prescriber and beneficiary information, drug name/strength/form, directions, quantity, duration, diagnosis and DX code, and prescriber signature/date.
Pennsylvania prescribers must query the PA PDMP when prescribing opioids or benzodiazepines.

Step Therapy

Step Therapy / Preferred Agent Trial Requirements

For non-preferred buprenorphine products, a trial and failure (or documented contraindication/intolerance) of preferred agents is required. Complete the applicable checklist item on the PA form and attach evidence of prior therapy or documented clinical rationale.

Non-preferred sublingual buprenorphine (film, tablet): document trial and failure or contraindication/intolerance to preferred sublingual buprenorphine products (see preferred drug list).
Non-preferred non-sublingual buprenorphine (e.g., injection): document trial and failure or contraindication/intolerance to preferred non-sublingual buprenorphine products.
Lucemyra (lofexidine): document trial and failure or contraindication/intolerance to clonidine tablet when applicable.
Reference for preferred/non-preferred agents: https://papdl.com/preferred-drug-list

Documentation Required

Submit Completed Form and Clinical Documentation

Complete all required fields on the PA form and submit the form with supporting clinical documentation. Failure to include required documentation will delay review and may result in denial.

Required form fields: prescriber and beneficiary information, drug name, strength, dosage form, directions, quantity, duration, diagnosis with DX code, prescriber signature and date.
Attach supporting documentation: prior treatment history, evidence of trials/failures or contraindications/intolerances, and any relevant clinical records.
Naloxone availability note: Naloxone is available via PA standing order and may be provided free to Medical Assistance beneficiaries through the prescription benefit.

Denial Risk

Documentation Missing Triggers Denial

Missing or incomplete documentation (including absence of a diagnosis DX code or lack of required clinical justification) may lead to denial of the prior authorization request.

Omissions that trigger denial: missing DX code, missing documentation of preferred-agent trials or documented contraindications/intolerances, unsigned or undated prescriber signature, or missing supporting clinical records.
Ensure all checklist items that apply are checked and backed by documentation before faxing the form.

Initial Drug-Specific Requirements

Initial drug-specific requirements

Initial prior authorization requires documentation of trials or contraindications to preferred agents where applicable.

Sublingual buprenorphine non-preferred: Documentation of trial and failure or contraindication/intolerance to preferred sublingual buprenorphine products.N/A

Refer to https://papdl.com/preferred-drug-list for preferred agents.

Non-sublingual buprenorphine non-preferred: Documentation of trial and failure or contraindication/intolerance to preferred non-sublingual buprenorphine products.N/A

Refer to https://papdl.com/preferred-drug-list for preferred agents.

Lucemyra (lofexidine): Documentation of trial and failure or contraindication/intolerance to clonidine tablet.N/A

Step Therapy Requirements

Step	Requirement
1	For a non-preferred SUBLINGUAL buprenorphine product (e.g., film, tablet): documentation that the member tried and failed or has a contraindication or intolerance to the preferred sublingual buprenorphine treatments. Refer to https://papdl.com/preferred-drug-list for preferred agents.
2	For a non-preferred NON-SUBLINGUAL buprenorphine product (e.g., injection): documentation that the member tried and failed or has a contraindication or intolerance to the preferred non-sublingual buprenorphine treatments. Refer to https://papdl.com/preferred-drug-list for preferred agents.
3	For Lucemyra (lofexidine): documentation that the member tried and failed or has a contraindication or intolerance to clonidine tablet.

OpenPayer

Opioid Use Disorder treatments prior authorization

Coverage Criteria for Opioid Use Disorder Treatments

Provider Actions, Submission & Documentation Requirements

Background

Definitions and Program Terms

Initial Drug-Specific Requirements

Step Therapy Requirements