buprenorphine/naloxone (Suboxone, Zubsolv, Bunavail)


Indications for Prior Authorization:

  • Treatment of opioid dependence

Patients must meet the following criteria for the indications above:

  • Providers must receive specialized training and be certified to prescribe buprenorphine/naloxone
  • buprenorphine/naloxone sublingual tablets is the preferred agent
    • Use of any other product requires chart note documentation of trail/failure/intolerable side effects to the sl tabs

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • Pain
  • Chronic narcotic maintenance is not a covered benefit
  • Any diagnosis not listed above as a covered indication

Treatment Phases:


  • The goal of induction is to safely suppress opioid withdrawal as rapidly as possible with adequate doses of buprenorphine/naloxone sl tablets
  • Patients cannot begin their induction to buprenorphine/naloxone sl tablets (and off of their previous opioid) until they are experiencing mild-to-moderate withdrawal symptoms


  • Is complete when the patient experiences no withdrawal symptoms, no uncontrollable opioid cravings, and minimal to no side effects
  • The induction phase usually averages about 2 to 5 days


  • During stabilization, the patient's buprenorphine/naloxone sl tablets dose is "fine-tuned."
  • The objective is to find the minimum dose necessary to keep the patient in treatment
  • After each dose adjustment, 3 to 7 days should be allowed for steady-state blood levels to be achieved
  • Stabilization can last anywhere from a week to several weeks
  • The maximum FDA approved dose is 24 mg per day


  • The goals of the maintenance phase are to prevent opioid withdrawal symptoms, suppress opioid cravings, and greatly attenuate the use of self-administered opioids
  • Patients may be maintained on buprenorphine/naloxone sl tablets from a maximum of 12months before initiation of Medically Supervised Withdrawal

Medically supervised withdrawal

  • In this phase, the buprenorphine/naloxone sl tablets dose is slowly tapered
  • Mild withdrawal symptoms are possible as the buprenorphine/naloxone sl tablets dose declines


Last review date: December 2, 2014

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