Subject: Buprenorphine Limit Policy 2897-H 12-2023

Drug

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.

 

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
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:

1. Buprenorphine sublingual tablets [package insert]. Berkeley Heights, NJ: Hikma Pharmaceuticals USA Inc.; September 2023.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Waltham, MA: UpToDate, Inc.; 2023. https://online.lexi.com. Accessed October 25, 2023.
3. Micromedex (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 10/25/2023).
4. 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 14, 2024