Subject: Buprenorphine-Naloxone Limit Policy 1553-H 12-2022

Drug

BUNAVAIL  (buprenorphine and naloxone buccal film)

CASSIPA  (buprenorphine and naloxone sublingual film)

SUBOXONE  (buprenorphine and naloxone sublingual tablet and film)

ZUBSOLV  (buprenorphine and naloxone sublingual tablet)

Policy:

FDA-approved Indications
Bunavail
Bunavail is indicated for the treatment of opioid dependence. Bunavail should be used as part of a complete treatment plan that includes counseling and psychosocial support.

Cassipa
Cassipa is indicated for the maintenance treatment of opioid dependence. Cassipa should be used as part of a complete treatment plan to include counseling and psychosocial support.

Suboxone Film
Suboxone sublingual film is indicated for treatment of opioid dependence. Suboxone sublingual film should be used as part of a complete treatment plan that includes counseling and psychosocial support.

Suboxone Tablet
Buprenorphine and Naloxone sublingual tablets are indicated for the maintenance treatment of opioid dependence.   Buprenorphine and Naloxone sublingual tablets should be used as part of a complete treatment plan that includes counseling and psychosocial support.

Zubsolv
Zubsolv is indicated for treatment of opioid dependence. Zubsolv should be used as part of a complete treatment plan that includes counseling and psychosocial support.

 

INITIAL LIMIT QUANTITY   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
Bunavail 2.1 mg/0.3 mg, 4.2 mg/0.7 mg	3 units / day
Bunavail 6.3 mg/1 mg	2 units / day
Cassipa 16 mg/4 mg	1 unit / day
Suboxone 2 mg/0.5 mg, 4 mg/1 mg,   8 mg/2 mg	3 units / day
Suboxone 12 mg/3 mg	2 units / day
Zubsolv 0.7 mg/0.18 mg, 1.4 mg/0.36 mg,   2.9 mg/0.71 mg, 5.7 mg/1.4 mg	3 units / day
Zubsolv 8.6 mg/2.1 mg	2 units / day
Zubsolv 11.4 mg/2.9 mg	1 unit / day

 

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Bunavail [package insert]. Raleigh, NC: BioDelivery Sciences International, Inc.; June 2022.
2. Buprenorphine and Naloxone tablets [package insert]. Lake Forest, IL: Akorn Operating Company, LLC; June 2022.
3. Cassipa [package insert]. North Wales, PA: Teva Pharmaceuticals USA, Inc.; June 2022.
4. Suboxone films [package insert]. North Chesterfield, VA: Indivior, Inc.; June 2022.
5. Zubsolv [package insert]. Morristown, NJ: Orexo US, Inc.; June 2022.
6. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2022; Accessed October 4, 2022.
7. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: http://www.micromedexsolutions.com/. Accessed October 4, 2022.
8. Cunningham C, Edlund MJ, Fishman M, et al. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 focused update. American Society of Addiction Medicine. January 2020. 1-91.

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 23, 2023