buprenorphine/naloxone (Suboxone, Zubsolv, Bunavail)
SELF ADMINISTRATION - Oral
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.
- chronic narcotic maintenance is not a covered benefit
- any diagnosis not listed above as a covered indication
Induction: 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.
Induction 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.
Stabilization: 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.
Maintenance: 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.
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: December 2014 Reviewed:
Reviewed and approved by Dr. R. Shain (Magellan Behavior Health)