CurrentUnitedHealthcarePolicy N/A

Suboxone/Subutex (buprenorphine/naloxone) prior authorization form — New York

Prior authorization request form for buprenorphine-containing products (Suboxone/Subutex and equivalents) for treatment of opioid use disorder; used by providers to request new or continuation therapy for UnitedHealthcare members (New York form).

Policy Summary

PayerUnitedHealthcare

PolicySuboxone/Subutex (buprenorphine/naloxone) prior authorization form — New York

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization is required for new or continuation requests; fax completed form to 866-940-7328 and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursminimum review time stated

866-940-7328fax number

800-310-6826phone

24 mgdaily buprenorphine threshold

Coverage Criteria

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Initial and continuation authorization criteria

Covered when ALL of the following are met:

Primary criteria: 1) Patient has a DSM-5-TR diagnosis of opioid use disorder; 2) Provider submits a completed prior authorization form including required member and provider information, ICD-10 diagnosis code, medication strength/directions, quantity, and prior medication trial history; 3) For continuation requests, provider documents that the patient has been prescribed a buprenorphine product for opioid use disorder maintenance therapy and provides the date of the prior prescription; 4) If the requested quantity exceeds 24 mg of buprenorphine daily (or equivalent), this is indicated on the form and may require additional justification.

See form fields for specifics and prior medication trials documentation.

Coding and Dosing

Diagnosis codes (to be provided)ICD-10

ICD-10 CODE

Requested diagnosis code field (specific ICD-10 code to be provided by prescriber)

Maximum referenced buprenorphine daily dose

Maximum referenced daily dose24 mg buprenorphine per day (or equivalent) — requests exceeding this amount must be indicated and may require additional justification

Context of thresholdForm asks: 'Does the requested quantity exceed 24mg of buprenorphine daily or equivalent dosing of an alternative medication?'

Potential consequenceRequests exceeding 24 mg/day without appropriate justification may trigger additional review or be considered not medically necessary

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for both new requests and continuation of therapy. Allow at least 24 hours for review.

Prior authorization required for new or continuation requests.
Allow at least 24 hours for review.

Documentation Required

Required Documentation on Form

Complete the prior authorization form with the following required documentation. Incomplete forms may delay or result in denial of the request.

Member demographics: first and last name, DOB, member ID, address, phone.
Provider information: name, NPI, MDID/O, specialty, office contact, phone and fax.
Medication details: drug name, strength, directions for use, quantity requested.
Diagnosis with ICD-10 code and indication; specify DSM-5-TR diagnosis of opioid use disorder (see denial triggers).
Pregnancy status and due date if applicable.
Previous medication trials: medication name, strength, directions, dates of therapy, reason for failure/discontinuation.
For continuation requests: date therapy started and provider signature.

Documentation Required

Preferred Alternatives Explanation

If preferred formulary alternatives are listed on the UnitedHealthcare PDL, the provider must document why those alternatives are unsuitable for this patient.

Explain clinical rationale why preferred buprenorphine/naloxone formulations on the PDL would not meet the patient’s needs (e.g., allergy, intolerance, previous failure, formulation not appropriate for route of administration, or other medical contraindication).
Reference the UnitedHealthcare PDL when applicable and provide supporting clinical notes.
If the request is for non-preferred product because of a special circumstance, describe the circumstance in detail.

Denial Risk

Triggers for Potential Denial

Requests may be denied if required information or clinical justification is missing.

Absence of a DSM-5-TR diagnosis of opioid use disorder.
Requested daily buprenorphine dose exceeding 24 mg without clinical justification.
Failure to document why preferred formulary alternatives are unsuitable.
Incomplete member or provider information, missing ICD-10 diagnosis code, or missing provider signature for continuation requests.

Medication-Assisted Treatment (Buprenorphine/Naloxone)

Medication-Assisted Treatment (buprenorphine/naloxone)

Medication-Assisted Treatment (buprenorphine/naloxone): DSM-5-TR diagnosis of opioid use disorder; documentation of current and prior buprenorphine-containing medication, dosing (including equivalent dosing when using alternative formulations), and prior medication trial history; pregnancy status and reason why preferred formulary buprenorphine products are not suitable when applicable.<= 24 mg buprenorphine daily referenced; requests exceeding 24 mg/day (or equivalent) must be indicated and may require justification.

Includes equivalent dosing guidance for alternative buprenorphine formulations (see form for Bunavail and Zubsolv equivalents).

Background

This authorization form is used to request approval for buprenorphine-containing products for maintenance therapy of opioid use disorder. It collects key clinical information required to evaluate maintenance treatment, including confirmation of a DSM-5-TR diagnosis of opioid use disorder, reasons why prescribed buprenorphine formulations are needed or why preferred formulary options cannot be used, and whether the requested dose exceeds the referenced 24 mg/day buprenorphine threshold.