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 200814Adobe PDF Library 15.0