Buprenorphine / Naloxone (Generic Suboxone) Tablets Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
buprenorphine / naloxone (generic Suboxone) tablets
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: __________________________________
Prescribing Physician: ____________________________
Patient ID #:
__________________________________
Physician Address:
_____________________________
Patient DOB: __________________________________
Physician Phone #:
_____________________________
Date of Rx:
__________________________________
Physician Fax #:
_____________________________
Patient Phone #: _______________________________
Physician Specialty:
____________________________
Patient Email Address: ___________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
buprenorphine / naloxone
____________
______________________
Specify: _________________
(generic suboxone) tablets
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
□
□
Yes
No
Patient is being treated for opioid use disorder
□
□
Yes
No
Patient is 16 years of age or older
□
□
Yes
No
Please provide prescribers Drug Addiction Treatment Act (DATA) 2000 waiver identification number
(that is, X DEA number): __________________________
□
□
Yes
No
Patient and prescriber have a formal written agreement regarding treatment for opioid use disorder
□
□
Yes
No
Patient is participating in a comprehensive rehabilitation program (consisting of either inpatient or
outpatient services) that includes psychosocial support provided by a program counselor qualified
by education, training, or experience to assess the psychological and sociological background of
patients receiving treatment
□
□
Yes
No
Patient is utilizing buprenorphine with naloxone in combination with any of the following medications
without written documentation from the prescriber of buprenorphine with naloxone regarding
medical necessity and evidence that patient has been counseled on the risk of concomitant use:
Opioid agents (including tramadol); Sedative/hypnotic agents (including non-benzodiazepine
hypnotics and phenobarbital containing agents); Benzodiazepine agents
Additional Questions for Maintenance Therapy:
□
□
Yes
No
Prescriber is utilizing the state prescription drug monitoring program (PDMP) where applicable by
state regulation prior to issuing prescription to ensure patient is not concurrently utilizing opioids,
benzodiazepines or sedative/hypnotic agents
□
□
Yes
No
Patient has undergone random clinical drug testing a minimum of eight times per year with either of
the following noted (please indicate):
□
Patient has a negative urine drug screen for opioids and other illicit substances (such as but not
limited to cocaine and methamphetamine) and a positive result for buprenorphine to continue
current treatment plan
□
If positive drug screen (for opioids or other illicit substances) or negative drug screen for
buprenorphine, evidence that the treatment plan has been re-evaluated and amended to achieve
treatment goals
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Buprenorphine with naloxone (generic Suboxone) NTL PAB Fax Form 01.11.16.doc
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