Subject: Buprenorphine Limit Policy 2897-H 12-2021
|
buprenorphine sublingual tablets
|
Policy:
FDA-approved Indications
Buprenorphine sublingual tablets are indicated for the treatment of opioid dependence and are preferred for induction. Buprenorphine sublingual tablets should be used as part of a complete treatment plan to include counseling and psychosocial support.
|
LIMIT CRITERIA
This limit is coded for daily dose. Limits do not accumulate together. Patient is allowed
the maximum limit for each drug and strength.
|
|
Drug
|
Daily Limit
|
|
Buprenorphine SL tab 2 mg
|
3 units/day
|
|
Buprenorphine SL tab 8 mg
|
3 units/day
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Buprenorphine sublingual tablets [package insert]. Parsippany, NJ: Teva Pharmaceuticals; August 2021.
- Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2021; Accessed November 9, 2021.
- Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed November 9, 2021.
- American Society of Addiction Medicine National Practice Guideline For the Treatment of Opioid Use Disorder. https://www.asam.org/docs/default-source/quality-science/npg-jam-supplement.pdf?sfvrsn=a00a52c2_2. Accessed November 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
April 09, 2022
