The dose of butrans is individualized and based on the patients medical condition, the severity of the pain, and other factors. The express scripts prior prescription rx authorization form is a document that is used by a patients prescriber in order to request that a certain nonpreferred or nonformulary medication be covered under their insurance policy. Prior authorization criteria for butrans buphrenorphine transdermal system background. The recommended method for submitting a pa request is to key it directly into the secure nctracks provider portal. Its standard operating procedure in a messedup medical system, says one expert. Belbuca butrans prior authorization request form please complete this entire form and fax it to. Prior authorization criteria for butrans buphrenorphine. It is important to change the skin site where you apply your butrans patch every week exactly 7 days, making sure that at least 3 weeks 21 days pass before you reuse the same site if you are wearing a patch, remember to remove it before applying a new one. Initial prior authorization pa form for oral buprenorphine. Please reference the following document for more details.
Effective february 1, 2019, buprenophine buccal film belbuca and buprenorphine transdermal patch butrans will no longer require prior authorization pa. If you require a prior authorization for a medication not listed here, please contact upmc health plan pharmacy services at 1800979upmc 8762. Example of maximum recommended dose per product label. Butrans is for transdermal use on intact skin only. Belbuca butrans rhode island prior authorization request form please complete this entire form and fax it to. Management of moderate to severe chronic pain in patients who require aroundtheclock opioid analgesic. Oct 16, 2014 the buprenorphine transdermal patch is included under the risk evaluation and mitigation strategy rems.
Pain is not postoperative unless the member is already receiving chronic opioid therapy prior to surgery, or if the. Patch application, rotation, and disposal instruct your patients on the administration of their butrans patch administration of butrans. Never tell a child that the buprenorphine skin patch is a bandage. Changed na to buprenorphine transdermal patch, butrans.
The use of this form is mandated for prior authorization requests concerning commercial fully insured members. Instruct patients to avoid exposing butrans to external heat sources, hot water, or prolonged direct sunlight see warnings and precautions 5. Butrans pain patch withdrawal spondylitis association of. Buprenorphine, sold under the brand name subutex, among others, is an opioid used to treat opioid use disorder, acute pain, and chronic pain. Never wear more than 1 patch at a time unless your doctor has told you to. What is butrans buprenorphine transdermal system ciii. Go to covermymeds to submit a prior authorization request. Certain states require humana to communicate prior authorization modifications before the effective date. Butrans patch fda prescribing information, side effects.
Drug request forms prior approval pa is required for certain drugs prescribed to n. Prior authorization criteria for butrans amazon s3. Ask for assistance if you cannot apply the patch yourself. Forms for authorization, behavioral health, pharmacy services and miscellaneous purposes for wellcare of florida providers. Prior authorization of benefits center at 18445129004.
Buprenorphinecontaining products for opioid substance use disorder. Additional quantities may be granted with satisfactory prescriber explanation during the first and last months of therapy to allow for dose titration to 4. Buprenorphine transdermal delivery system butrans, ciii national drug monograph october 2015. The butrans patch should be applied to a relatively hairless or nearly hairless skin site. Butrans 20 mcghour may not provide adequate analgesia for patients requiring greater than 80 mgday oral morphine equivalents. An example of an easy transition is me i was taking 110 10325mg norcos daily for years.
Montana medicaid buprenorphinecontaining products for opioid. Instruct patients to apply the patch immediately after removal from the individually sealed pouch. Elimination of belbuca and butrans from longacting sustained. When changing the system, instruct patients to remove butrans and dispose of it properly see dosage and administration. Prior authorization prior authorization is a routine process. Butrans buprenorphine buccal film and butrans buprenorphine transdermal system will be covered with prior authorization when the following criteria are met. Silverscript insurance company prescription drug plan p. Persons with disabilities having problems accessing the pdf files below may call 301 7963634 for assistance. Butrans can be used as an alternative to treatment with other opioids. Patient has had a trial and therapy failure with fentanyl patch at maximum tolerated. It is covered by some medicare and insurance plans, but some pharmacy coupons or cash prices may be lower.
Please contact cvscaremark at 18667729538 with questions regarding the prior authorization process. The following document outlines the drugs affected by prior authorization modifications. Butrans buphrenorphine transdermal system is a transdermal formulation of buprenorphine indicated for the management of moderate to severe chronic pain in patients requiring a continuous, aroundtheclock opioid analgesic for an extended period of time. Prior authorization for buprenorphine means deadly delays in accessing treatment for some patients. Butrans medicare coverage and copay details goodrx. Here are the ways your doctor can request approval.
Choose an area of nonirritated, intact skin on your upper arm, outer arm, upper chest, upper back or side of the chest. Butrans is a skin patch that delivers buprenorphine. Medically necessary click to close to be medically necessary means it is appropriate, reasonable, and adequate for your condition. Use of butrans as the first opioid analgesic initiate treatment with butrans with a 5 mcghour patch. Prior authorization form fchp commercial butrans fchp this fax machine is located in a secure location as required by hipaa regulations. Avoid allowing children to watch you put on a skin patch. If transdermal patch falls off during the 7 days, discard patch and apply new patch to different skin site. Butrans is designed for long term so you only need apply a new patch every 7 days and as such it takes time to work thru your skin and to your brain. Forms are updated frequently and may be barcoded member information. Assess each patients risk prior to prescribing butrans, and monitor all patients regularly for the development of these behaviors and conditions see warnings and precautions 5. If the patient is not able to meet the above standard prior authorization requirements, please call 18007114555. This drug is slightly less popular than comparable drugs. Dailymed butrans buprenorphine patch, extended release. Read the medication guide and, if available, the patient information leaflet provided by your pharmacist before you start.
Prior authorization form buprenorphine products hmf this fax machine is located in a secure location as required by hipaa regulations. If problems with the patch not sticking continue, cover the patch with special seethrough adhesive dressings for example bioclusive or. Impairment of fertility butrans 14 of a butrans 5 mcghour, one butrans 5 mcghour, or one butrans 20 mcghour every 3 days in males for 4 weeks prior to mating for a total of 10 weeks and in females for 2 weeks prior to mating through gestation day 7 had no effect on fertility or general reproductive performance of rats at aucbased. Prior total daily dose of opioid greater than 80 mg of oral morphine equivalents per day. Initial prior authorization pa form for oral buprenorphine formerly known as subutexsuboxone buprenorphine naloxoneplease complete form and fax to 18883434232if the following information is not completed in full, correct, andor legible, the pa process may be delayed and could result in a denial. Each butrans patch is intended to be worn for 7 days. Buprenorphine transdermal delivery system butrans, ciii national drug monograph. Prior authorizationmedical necessity buprenorphine products. The requested medication is not being used for opioid dependence. Butrans buprenorphine patch, extendedrelease prior. It can be used under the tongue, in the cheek, by injection, as a skin patch, or as an implant. The health plan will notify you of its prior authorization decision via fax on the date the actual decision is made.
Buprenorphine transdermal delivery system butrans, ciii. Instruct patients not to use butrans if the pouch seal is broken or the patch is cut, damaged, or changed in any way and not to cut butrans. Ub04 submission sample please refer to nubc national uniform billing committee ub04 forms for complete detailed information about paper claim submission and refer to the 837 institutional implementation guide by washington publishing company may 2006 for any edi related issues. If your office is unable to receive faxes, you will be notified via u. Buprenorphine butrans is an expensive drug used to treat moderate to severe pain. When conditions are met, we will authorize the coverage of buprenorphine products hmf. Butrans should be administered every 7th day patients aged 18 years and over the lowest butrans dose butrans 5 microgramhour transdermal patch should be used as the initial dose. Ankylosing spondylitis information, ankylosing spondylitis treatment, ankylosing spondylitis forums, ankylosing spondylitis diagnosis, articles on ankylosing. This form is used to determine coverage for prior authorizations, nonformulary medications, and medications with utilization management rules. Use of butrans in opioidexperienced patients requires that the patient be tapered to no more than 30mgd mse for up to 7 days prior to starting treatment with butrans. Butrans buprenorphine is a narcotic analgesic used to help relieve moderate to severe ongoing pain such as due to arthritis, chronic back pain. Butrans buprenorphine prior authorization request form page 1.
Authorization resources medication lookup blue cross blue shield. For certain prescription drugs, additional coverage requirements may be in place to ensure that our members use these drugs in a safe way, while also helping to control costs for everyone. Statespecific prior authorization request form, pdf opens new window. It will be required of the prescriber that they provide justification for why theyre choosing to prescribe an alternative drug, one which is atypical and. Common and rare side effects for butrans transdermal. Tell your doctor if you have serious side effects of butrans including. To avoid irritation, apply to a different area each time and do not apply to the same site within 3 weeks. Butrans transdermal patch, belbuca buccal film medication class.
Refer to the prior approval drugs and criteria page for specific criteria. Butrans 14 of a butrans 5 mcghour, one butrans 5 mcghour, or one butrans 20 mcghour every 3 days in males for 4 weeks prior to mating for a total of 10 weeks and in females for 2 weeks prior to mating through gestation day 7 had no effect on fertility or general reproductive performance of rats at aucbased exposure levels as high as. Oct 18, 2019 if butrans falls off during the 7day dosing interval, dispose of the transdermal system properly and place a new butrans patch on at a different skin site. Providers may submit requests via fax, phone or through the secure nctracks secure provider portal. Butrans buprenorphine transdermal dosing, indications. Clinical edit details 150mg aliskirencontaining agents prior authorization form addendum prior authorization criteria logic 300mg aliskirencontaining agents prior authorization form addendum prior authorization criteria logic actiq prior authorization form addendum prior authorization criteria logic. Consideration should be given to the previous opioid history of the patient see section 4. Whose prescription drug coverage was sold in the state of california. Pharmacy prior authorization providers upmc health plan. Butrans 5, 10 and 20ugh transdermal patch summary of. Belbuca butrans rhode island prior authorization request.
Almost 70% of medicaid plans require prior authorizations for buprenorphine. Relistor prior authorization form upmc health plan. Express scripts prior prescription rx authorization form. Find prior authorization guidelines and forms humana. Butrans buprenorphine transdermal system for transdermal administration 5 mcghour, 10 mcghour, and 20 mcghour company. For opioid use disorder, it is typically started when withdrawal symptoms have begun and for the first two days of treatment under direct observation of a. Jan 04, 2012 prior authorization criteria for butrans buphrenorphine transdermal system background. Please contact cvs caremark at 18555822022 with questions regarding the prior authorization process. Relistor prior authorization form if this is an urgent request, please call upmc health plan pharmacy services. There are no nonorally administered opioids on formulary other than fentanyl patches. Drug name select from list of drugs shown butrans buprenorphine 10mcghour transdermal butrans buprenorphine 15mcghour transdermal. Apr 26, 2018 prior authorization for buprenorphine means deadly delays in accessing treatment for some patients. Please complete all pages to avoid a delay in our decision.
Opioid agonistantagonist analgesics fdaapproved uses. Oct 01, 2019 butrans 14 of a butrans 5 mcghour, one butrans 5 mcghour, or one butrans 20 mcghour every 3 days in males for 4 weeks prior to mating for a total of 10 weeks and in females for 2 weeks prior to mating through gestation day 7 had no effect on fertility or general reproductive performance of rats at aucbased exposure levels as high as. The requested drug is being prescribed for pain severe enough to require daily, aroundtheclock, longterm. Prior authorization approval criteria fallon health. Purdue will ensure that no later than 3 weeks prior to first availability of butrans to healthcare professionals, a dear healthcare professional letter will be mailed to prescribers. Medicare part d formulary exceptions and prior authorizations. Apply first aid tape only to the edges of the patch. Long acting opioid prior authorization criteria select health of. Pre pa allowance priorapproval requirements caremark. Prior approval pa is required for certain drugs prescribed to n. Such patients should be started on the lowest available dose butrans 5 microgramhour transdermal patch and continue taking shortacting supplemental analgesics see section 4. Find information about common, infrequent and rare side effects of butrans transdermal. Notice of changes to prior authorization requirements. The buprenorphine transdermal patch butrans is fdaindicated for use in patients with pain that is severe enough to require daily, aroundtheclock, longterm opioid use for which other treatments are not adequate.
Prior authorization program information current 4120. Butrans patch fda prescribing information, side effects and. Changed prior authorization will be granted for up to 4 patches per 28 days. Amid opioid crisis, insurers restrict pricey, less addictive. Butrans exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Request for medicare prescription drug coverage determination this form may be sent to us by mail or fax.
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