Subutex & Suboxone policies

[diana.papshev]

Anonymous member request:

"I was ‘searching’ on the forum trying to find information regarding Subutex, specifically coverage policies or criteria for use.

I think it would be interesting to see what other plans are doing with this drug. We have taken a hard stand. We have it excluded under the pharmacy benefit secondary to prescribing language recommending induction be done in the physicians office under supervision. Suboxone is however covered under pharmacy – post induction. We don’t see a problem with this for the docs using it for substance abuse but we have had trouble with those docs wanting to use it off-label for pain, which we in no way support.

Also, Subutex is available to docs through our specialty vendor for medical reimbursement under a diagnosis of substance abuse."

[chantell.reagan]

Seven publicly available policies for opioid dependence agents (buprenorphine-containing agents) from regional and national health plans have been evaluated. The following are key findings for Subutex (buprenorphine) and Suboxone (buprenorphine/naloxone):

• None of the 7 plans limit Subutex induction to the medical benefit
•6 plans with PA policies allow use of Subutex for induction; 5/6 plans have explicit criteria allowing Subutex maintenance therapy for pregnant patients and/or those with intolerance to Suboxone
•2 commercial plans do not require PA for generic Subutex or lower quantity of Suboxone
•5/7 plans have designated physician requirements for prescribing Suboxone or Subutex
•Quantity limits tend to vary among the plans
•None of the 6 plans with PA policies allow coverage for pain

Of note, a generic version of Subutex was approved in late-2009, and some policies were updated before this time. Please see the attached document with the table, which compares 7 publicly available national and regional policies.

To view this analysis, you must login first (if you haven't registered yet, please click here, registration is free). After you have logged-in, please scroll down and click on the attached PDF file at the bottom of this page.

Sources:
Aetna Clinical Policy Bulletin: Narcotic Partial Agonists (Step-therapy criteria) (link in attachment)

AmeriHealth Mercy prior authorization form: Aetna Clinical Policy Bulletin: Narcotic Partial Agonists (Step-therapy criteria): (link in attachment)

AmeriHealth Mercy prior authorization form: (link in attachment)

BlueCross BlueShield of Alabama: (link in attachment)

Highmark Blue Shield: (link in attachment)

Health Spring 2009 Prior authorization criteria: (link in attachment)

UPMC Buprenorphine/Naloxone (Suboxone) and Buprenorphine (Subutex) policy: (link in attachment)

United Healthcare (Oxford): Opioid Dependence Agents (Suboxone, Subutex): (link in attachment)l

United Healthcare (Oxford): Opioid Dependence Agents (Suboxone, Subutex: Prescription Drug Quantity Duration (QD) and Quantity Level Limitations (QLL): (link in attachment)

[Nochmar]

We currently have these items covered without restriction. From a utilization standpoint, we seem to have an "appropriate" level of utilization. I have not seen off-label utilization for pain in our plan.

I would recommend running a periodic report to look for simultaneous Suboxone and narcotic use. In my last analysis, I found two or three cases of interest. It's a major investment to treat these folks and keeping them on the straight and narrow is well worth it.