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suboxone-subutex by wanghonghx

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									                                               Prior Authorization Form
                                               Date Criteria: 11/1/2010

                                     CAREFIRST BLUECROSS BLUE SHIELD

                                                     Subutex, Suboxone

             Complete information, sign and date. Fax completed forms to Argus at 1-800-315-4025.
                This fax machine is located in a secure location as required by HIPAA regulations.

               When conditions are met, we will authorize coverage of Subutex or Suboxone.
     Please contact Argus at 1-800-314-2872 with questions regarding the prior authorization process.

Patient:
Patient Name:___________________________________
Patient ID:______________________________________
Patient's Group Number:___________________________
Patient's Date of Birth:___________________________

Prescribing Physician:

Physician Name:_____________________________________
Physician Phone:____________________________________
Physician Fax:______________________________________
Prescriber ID:_______________________________________
Physician Address:___________________________________
Physician City, State, Zip:______________________________


FAILURE TO COMPLETE FORM IN IT’S ENTIRETY MAY RESULT IN A DENIAL OF REQUEST.


Drug: ______________________________________Strength: __________________________________________

Dosage: ____________________________________Duration of therapy: __________________________________


1. Does the patient have a diagnosis of opioid dependence? If no, please provide diagnosis.

   ________________________________________________________________________________________

2. Does the prescribing physician have a valid Drug Addiction Treatment Act (DATA) waiver allowing him/her
   to prescribe Subutex or Suboxone for opioid dependence?

   If yes, please provide the prescribing physician’s “X” DEA license number.

   _________________________________________________________________________________________

3. Did you recommend to this patient addiction counseling and/or other non-pharmacologic therapy and/or 12-step
   program such as NA or AA?
   ___________________________________________________________________________________________
   Information given on this form is accurate as of this date.


  _________________________________________________________________________________________
  Prescriber or Authorized Signature                                  Date




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