Buprenorphine Transdermal Patch and Buccal Film

Drug - Buprenorphine Transdermal Patch and Buccal Film

September 2018

Preferred	Nonpreferred
Butrans	buprenorphine transdermal patch
	Belbuca

Approval criteria for preferred product

• Patient has chronic pain requiring daily, around-the-clock, long-term opioid treatment
• Patient must not have any one of the following:
  • Concurrent use of a long-acting opioid. If the patient is being transitioned from one opioid to Butrans, a discontinuation plan of the first opioid must be provided at time of request OR
  • Patient’s total daily dose of opioid from all sources > 80 mg of oral morphine equivalents OR
  • Patient’s current fentanyl prescription ≥ 50 mcg/hour OR
  • Patient’s concurrent use of Suboxone/Subutex or their generic equivalents

Quantity limit for the preferred product

• 4 patches of the same strength per 28 days supply
• Combination of patches of different strengths will not be approved

Approval criteria for the nonpreferred product

• Patient must meet all approval criteria for preferred product AND
• Patient has failed an adequate trial of the preferred product, unless contraindicated

OR

• If the request is for Belbuca AND the patient’s total daily dose of opioid from all sources > 80 mg but ≤ 160 mg of oral morphine equivalents, the patient must meet the following criteria:
  • Patient has chronic pain requiring daily, around-the-clock, long-term opioid treatment AND
  • Patient must not have concurrent use of a long-acting opioid. If the patient is being transitioned from one opioid to Belbuca, a discontinuation plan of the first opioid must be provided at time of request AND
  • Patient must not have concurrent use of Suboxone/Subutex or their generic equivalents

OR

• If the request is for Belbuca AND the patient’s total daily dose of Belbuca is 1200 mcg, 1500 mcg or 1800 mcg, the patient must meet the following criteria:
  • Patient has chronic pain requiring daily, around-the-clock, long-term opioid treatment AND
  • Patient must not have concurrent use of a long-acting opioid. In rare instances where the patient is on high dose of Belbuca and a long acting opioid, a discontinuation plan of the long-acting opioid must be provided at time of request.
  • Patient must not have concurrent use of Suboxone/Subutex or their generic equivalents

Quantity limit for the nonpreferred product

• 4 patches of the same strength per 28 days supply
• Combination of patches of different strengths will not be approved

OR

• 60 films of the same strength per 30 days supply
• Combination of films of different strengths will not be approved

OR

• Combination of films and patches will not be approved

Questions

MHCP Provider Call Center 651-431-2700 or 800-366-5411