Passport Health Plan Kentucky Medicaid Substance Use Treatment Pharmacy
Supplemental Prior Authorization Form For Buprenorphine Products
This form is to be used as a supplement with the Kentucky Medicaid Universal PA form for buprenorphine products.
This form will include the additional information needed for Passport Health Plan to completely process against our
Plan Criteria
This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
date. Fax signed forms to CVS/Caremark at 1-844-802-1406. Please contact CVS/Caremark at 1-844-380-8831 with
questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of
Buprenorphine Products.
1
Did the prescriber utilize one of the following diagnostic and/or screening tools: A) Diagnostic and Statistical
Manual of Mental Disorders, B) DAST, C) COWS Assessment?
Which tool was utilized in screening? _________________________________________________________
Yes
/ No
2
Has the patient had an emergency department visit or inpatient hospitalization due to medical/psychiatric
complication of opioid use (i.e., infection, acute suicidal ideation, etc.)?
Please list approximate date(s) and medical/psychiatric complication(s)
addressed._____________________________________________
Yes
/ No
3
Has a written explanation as to why the drug screens were negative for buprenorphine or norbuprenorphine been
submitted? Please submit documentation including an explanation of these negative results.
Yes
/ No
4
Were at least TWO drug screens within each 12 month period random and coupled with a pill count? Please
submit documentation listing date(s) and attach results from last 12 months.
Yes
/ No
5
Does the prescriber attest that at least 8 drug screens will or have been performed within each 12 month
period? Prescriber must document dates and attach results from last twelve (12) months.
Dates:_________________________________________________________________
Yes
/ No
6
Is it documented in the patient's chart the approximate date of relapse and how the relapse was managed?
Please submit documentation including the approximate date and how the relapse was managed.
Yes
/ No
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7
Does the patient have any untreated or unstable psychiatric conditions that would interfere with compliance
to a buprenorphine-containing product?
Yes
/ No
8
Are the psychiatric conditions stabilized and/or treated? ______________________________________
Yes
/ No
9
Have the prescriber AND patient signed the Passport Health Plan Statement of Understanding Form - Taking
Buprenorphine-Containing Products or an equivalent form?
Yes
/ No
10
Please submit documentation of the following "Statement of Understanding Form - Taking BuprenorphineContaining Products" has been reviewed with the patient, signed by the patient and the prescriber, and
attached to the request or the prescriber's version of the form must be signed by the patient and prescriber.
Yes
/ No
*The Plan allows for the prescriber to submit a form with the member's signature noted per phone.
11
Is it documented in the patient's chart the approximate date of relapse and how the relapse was managed?
Please submit documentation including the approximate date and how the relapse was managed?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Yes
/ No
12
Is the patient unable to take the preferred formulary alternatives for the given diagnosis due to a
documented allergy, intolerance, or contraindication?
Yes
/ No
13
Has the patient had a documented therapeutic failure to a trial of at least ONE preferred medications within
the same class?
Yes
/ No
14
Has a written explanation as to why the buprenorphine-containing product should be continued despite
apparent noncompliance been submitted?
Yes
/ No
Please see the next page for Statement of Understanding Form.
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Statement of Understanding Form – Taking Buprenorphine-Containing Products
I, [insert name]
, have talked to my provider about taking
buprenorphine-containing medicines. I understand and agree to the following:
 I have decided to take this medicine to help treat my addiction to narcotic drugs.
 I know from talking to my provider that there are risks and possible side effects linked to taking this
medicine.
 I agree to follow the therapy as ordered by my provider.
 I have had the chance to ask questions about this product, other treatment options, and the
risks of treatment. I have enough information to understand my treatment.
 I will tell my provider who is prescribing this medicine about any other provider or dentist
appointments. I will tell my provider about any prescription and non-prescription medicines
I am taking.
 I have been given a copy of this Statement of Understanding Form.
To help make my treatment a success, I agree to:






Go to all of my follow-up visits.
Take any alcohol or drug tests my provider orders. I know from talking with my provider that it
is unsafe to mix this medicine with alcohol and other drugs.
Store my medicine in a safe place. I will not share my medicine with anyone. I know it can
be unsafe for others.
Take this medicine as ordered by my provider. To get the most benefit from the medicine, I will
not skip any doses. I have been told how to take this medicine. I will place it under my tongue
to dissolve (melt) and be absorbed.
Get my prescriptions for this medicine only from the provider/provider group listed on this
agreement.
Go to counseling as part of treating my addiction.
By signing here, I agree to ALL of the bullet points on this form.
Signature:
Date:
Prescriber’s Signature:
Date:
PROV40935 APP_2/12/2015
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