PRIOR AUTHORIZATION FORM - MaineCare PDL
State of Maine Department of Health & Human Services
MaineCare/MEDEL Prior Authorization Form
Suboxone/Buprenorphine Continuation
Phone: 1-888-445-0497 ONE Drug Per Form ONLY – Use Black or Blue Ink Fax: 1-888-879-6938
Drug Name Strength Dosage Instructions Quantity Days Supply Refills
(34 retail)
Suboxone _____________ _________ ___________ 1 2 3 4 5
Buprenorphine _____________ _________ ___________ 1 2 3 4 5
Requesting current titration dose of ______________________ (+ or – 4mg)
Medical Necessity Documentation
Is the patient currently engaged in recovery oriented supports/services?
o Yes
o No
Has the patient’s level of functioning markedly improved since starting treatment with Suboxone?
o Yes
o No
Describe evidence of improvement in the following areas that apply to the patient:
o Family ____________________________________________________________________________________________________________________________________________________________________
o Legal ____________________________________________________________________________________________________________________________________________________________________
o Social ____________________________________________________________________________________________________________________________________________________________________
o Physical ____________________________________________________________________________________________________________________________________________________________________
o Occupational ___________________________________________________________________________________________________________________________________________________________________
o Spiritual ____________________________________________________________________________________________________________________________________________________________________
o Other ____________________________________________________________________________________________________________________________________________________________________
Has the patient previously tried to titrate down the dose of buprenorphine?
o Yes
o No
Was the attempt successful?
o Yes
o No
Do you and the patient plan to taper the dose in the next 3, 6, 12 months?
o Yes
o No
Do you anticipate being able to discontinue Suboxone treatment for this patient in the next 12 months?
o Yes
o No
If you answered no to any of the questions above, please provide an explanation:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Does the patient have a serious and persistent mental illness?
o Yes
o No
Does the patient have a child under age 3 in the home (full or part-time) for whom they are primarily responsible?
o Yes
o No
Is the patient pregnant?
o Yes
o No
Other than those listed above are there any special circumstances that would preclude this patient from attempting a taper? Explain:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pursuant to the MaineCare Benefits Manual, Chapter I, Section 1.16, The Department regards adequate clinical records as essential for the delivery of quality care, such comprehensive records are key documents for post payment review. Your authorization certifies that the above request is medically necessary, meets the MaineCare criteria for prior authorization, does not exceed the medical needs of the member and is supported in your medical records.
Provider Signature: _______________________________________________ Date of Submission: _______________________
*MUST MATCH PROVIDER LISTED ABOVE
Please complete both pages of this PA request
-----------------------
Member ID #: |__|__|__|__|__|__|__|__|__| Patient Name: ____________________________________ DOB: __________________
(NOT MEDICARE NUMBER)
Patient Address:_________________________________________________________________________________________________
Provider DEA: |__|__|__|__|__|__|__|__|__| Provider NPI: __|__|__|__|__|__|__|__|__|__|
Provider Name:_______________________________________________________________________ Phone:____________________
Provider Address:_____________________________________________________________________ Fax:____________________
Pharmacy Name:_____________________________Rx Address:________________________________Rx phone:_________________
Provider must fill all information above. It must be legible, correct and complete or form will be returned.
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