This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Suboxone / Subutex

Suboxone / Subutex

 

DESCRIPTION

Suboxone (buprenorophine/naloxone)/Subutex (buprenorophine) are Schedule III narcotics. Under the Drug Abuse Treatment Act (DATA) of 2000, they can be used to treat opioid addiction outside of Opioid Treatment Programs. Only providers with qualifying credentials as defined in DATA 2000 can prescribe or dispense Suboxone or Subutex for opioid addiction therapy. Qualified providers must submit a Notification of Intent, or a "waiver notification," to the Center for Substance Abuse Treatment (CSAT, a component of SAMHSA) prior to starting therapy. Providers approved by CSAT are issued a DATA 2000 Waiver Identification number, or a "X" number, by the DEA (Drug Enforcement Agency). Both the Waiver ID number and the prescriber's regular DEA number are required on Suboxone and Subutex prescriptions for opioid addiction therapy. Besides verifying that both DEA numbers are on the prescription, there are no additional requirements for pharmacists or pharmacies to dispense Suboxone or Subutex beyond those for other Schedule III medications.

Suboxone/ Subutex are subject to diversion and abuse. Suboxone contains naloxone to deter abuse by injection. Naloxone has no effect when used sublingually due to poor absorption. However, given intravenously, naloxone blocks opioid effect and precipitates immediate withdrawal. Subutex may be used for induction in some patients during the first 2-3 days. Subutex should be administrated with supervision. Suboxone is the preferred agent for maintenance therapy, especially when clinical use includes unsupervised administration. Maintenance therapy with Subutex should be limited to those patients who cannot tolerate Suboxone or who are pregnant or breastfeeding.

 

POLICY

Effective 8/1/12, prior authorization is required for Suboxone/Subutex when purchased at a pharmacy.

Initial treatment is approved for 6 months if the clinical criteria are met and the provider is authorized by SAMHSA to prescribe Suboxone/Subutex. A maximum of 24 months of therapy can be obtained per member lifetime. A quantity limit of 2 (two) tablets a day will be approved for Suboxone/Subutex.

Suboxone New Starts (Effective 8/1/12, a prior authorization is required for all new members taking Suboxone)
A new start Suboxone prescription may be considered medically necessary if the following criteria are met:

  1. The provider is listed on the Substance Abuse and Mental Health Services Administration (SAMHSA) website or has submitted a notification of intent, or a “waiver notification”, to the CSAT and has been approved/issued a DATA 2000 Waiver Identification number (see Appendix 1 Policy Guidelines) **BCBSMS will not recognize any “Immediate” providers as an authorized provider**, AND 
  2. The member is being treated for opioid dependence, AND
  3. The provider has provided a treatment plan and taper strategy, AND
  4. The member is 16 years of age or older.

Subutex New Starts (Effective 8/1/12, a prior authorization is required for all new members taking Subutex)
A new start Subutex prescription may be considered medically necessary if the following criteria are met:

  1. The provider has submitted a notification of intent, or a “waiver notification”, to the CSAT and has been approved/issued a DATA 2000 Waiver Identification number (see Appendix 1 Policy Guidelines) **BCBSMS will not recognize any “Immediate” providers as an authorized provider**, AND
  2. The member is being treated for opioid dependence, AND
  3. The provider has provided a treatment plan and taper strategy, AND
  4. The member is 16 years of age or older, AND
  5. The member is being treated for induction therapy, OR
  6. The member is being treated for “maintenance therapy” because of intolerance to Suboxone, OR
  7. The member is being treated for maintenance therapy because she is pregnant or breastfeeding.

Continuation of Therapy
Continuation of Suboxone/Subutex may be considered medically necessary if the following criteria are met:

  1. For continuation of therapy, providers will need to submit their treatment plan, taper strategy, and illicit drug use including problematic alcohol use within initiation treatment period (see Appendix 2 Policy Guidelines), AND
  2. The member is compliant with all elements of the treatment plan (including recovery-oriented activities, psychotherapy, and/or other psychosocial modalities), AND
  3. The prescriber has confirmed that the member has no concurrent opioid use or diverting their medication (see Appendix 2 in Policy Guidelines).

Effective 10/1/2012, a prior authorization will be required for members currently taking (defined as members on therapy as of 8/1/2012) Suboxone/Subutex if the member does not have an opioid dependence diagnosis and/or is being treated by a non-authorized provider. A 6-month continuation request may be approved based on an approved treatment plan and taper strategy for a maximum of 24 months per member lifetime. Existing members taking Suboxone/Subutex that have already received 24 months of therapy will only be given a 6-month continuation period in order to be tapered off therapy.

Suboxone/Subutex is considered investigational when used for all other conditions, including but not limited to:

  • Treatment of pain
  • Treatment of other substance dependence
  • Concurrent treatment of pain and opioid dependence 

 

POLICY EXCEPTIONS

Prior authorization for Suboxone/Subutex is not required for Federal Employee Program (FEP) and State Health Plan members.

 

POLICY GUIDELINES

Appendix 1

Verification of DATA 200 waiver to prescribe Suboxone/Subutex for the treatment of opioid addiction.

  • The SAMHSA Buprenorphine Physician Locator Web site lists the providers in each State who have DATA 2000 waivers. (http://www.buprenorphine.samhsa.gov/bwns_locator/index.html)
    • A provider listed on the site can be considered to have a valid DATA 2000 waiver.
    • This list is not complete; a provider with a valid waiver may choose not to be listed on the site. These providers will need to provide verification of their DATA 2000 waiver to BCBSMS.
    • BCBSMS will not recognize any “Immediate” providers as an authorized provider.

Appendix 2

Verification of no concurrent opioid utilization.

  •  Providers will register for access to the Mississippi Prescription Monitoring Program (PMP) in order to access patient profiles to ensure no concurrent opioid utilization is being administered to current Suboxone/Subutex patient.
    •  The application can be found at the Mississippi Board of Pharmacy website http://www.mbp.state.ms.us and click on the “Prescription Monitoring” tab. 

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

07/09/2012: New policy added. 

03/27/2014: Policy reviewed; no changes.

 

SOURCE(S)

Suboxone/Subutex Prescribing Information

Substance Abuse and Mental Health Services Administration (SAMHSA). Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addication.

American Pain Society. National Clinical Guideline. Use of Chronic Opioid Therapy in Chronic Non-Cancer Pain: Evidence Review.

SAMHSA. Buprenorphine Physician and Treatment Locator. http://www.buprenorphine.samhsa.gov/bwns_locator/index.html

 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Code Number

Description

CPT-4

 

 

ICD-9 Procedure

 

 

ICD-9 Diagnosis

304.00 - 304.02

Opioid type dependence code range

HCPCS

 

 

 

 

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