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Coverage Decisions for Drugs

Buprenorphine or buprenorphine/naloxone

Coverage decision - Effective July 1, 2013

Prior authorization is required for buprenorphine and buprenorphine/naloxone products. L&I may cover buprenorphine (Subutex®) or buprenorphine/naloxone (Suboxone®, Zubsolv®) for a limited time to aid in opioid weaning or opioid use disorder, but does not provide coverage for pain management or other off-label uses.

Coverage criteria

Opioid wean

The requesting provider must:

Authorization is limited to 30 days. An additional 30 days is available if requested and progress on the opioid wean has been documented.

Opioid use disorder

The requesting provider must:

  • document that the worker has failed steps 1 and 2 taper (see WAC 296-20-03030)
  • document that the worker is diagnosed with opioid use disorder by DSM V criteria and this condition is identified as a barrier to recovery; and
  • submit a time-limited plan documenting how temporary treatment of this condition through a licensed chemical dependency treatment center will allow significantly improved work capacity and/or the ability to progress in vocational retraining.

Payment for treatment of opioid use disorder is limited to six months per worker.

 


For more information:
Contact information.

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