23306 MedicaidPAFormBuprenorphineMonotherapy nob FNL R
Accessibility
Molina Healthcare
Buprenorphine-Monotherapy Patient Last Name
Prior Authorization for Buprenorphine Monotherapy Fax (800) 869-7791 | Phone (800) 213-5525
Patient First Name
Middle Initial Date of Birth Molina ID
Pharmacy Name
Pharmacy NPI
Pharmacy Telephone Number Pharmacy Fax Number
Prescriber Name
Prescriber NPI
Prescriber Telephone Number Prescriber Fax Number
Diagnosis
Medication and Strength
Qty/Days Supply
Directions for Use
Select from the following for your patient and complete associated question(s):
Patient is pregnant. Estimated delivery date (EDD): Was pregnancy confirmed with a lab test by the provider? Is buprenorphine prescriber managing patient's pregnancy? Has patient been stable on buprenorphine/naloxone for at least 8 weeks?
Yes Yes Yes
No No No
Patients approved based on pregnancy will be approved through 30 days after their EDD. When patient is no longer pregnant, transition to a buprenorphine/naloxone combination product is required for ongoing treatment unless patient is breastfeeding.
Patient is breastfeeding. Delivery date: Patients approved based on breastfeeding, will be approved for 12 months following delivery. Transition to a buprenorphine/naloxone
combination product is required for ongoing treatment thereafter.
Patient has experienced a documented serious allergic or idiosyncratic reaction to the buprenorphine/naloxone combination product. Chart notes documenting reaction are required.
Patient has continued to experience severe nausea or daily headache after trying at least two different formulations of buprenorphine/
naloxone combination products for at least 7 days each.
Indicate formulations tried for at least 7 days (check all that apply):
Buccal film
Sublingual tab
Sublingual film
Best practice is to limit patients to a 7-day supply at a time.
Indicate the intended days supply per fill for your patient:
7 day
14 day
28 day
If over a 7 day supply is indicated:
· Is the reason due to transportation complications? Yes
No
If no, provide reason:
· Has patient demonstrated evidence of stability (8 weeks of treatment) taking buprenorphine monotherapy
and/or buprenorphine/naloxone?
Yes
If yes, how long has patient been clinically stable?
No
I have read and understand Medication Treatment Guidelines for Substance Abuse Disorders (SUDs) Buprenorphine Containing Products (http://www.hca.wa.gov/billers-providers/programs-and-services/apple-health-medicaid-drug-coverage-criteria).
Prescriber Signature
Prescriber Specialty
Date
Notice Prohibiting Redisclosure of Alcohol or Drug Treatment Information
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you
from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom
it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for
this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
MHW Part #1263-2008 MHW-8/12/2020, HCA 11/1/2019 (13-330)
23306FRMMDWAEN 200814
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