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Blue Cross & Blue Shield of MississippiCommercial · Prior Auth · Medical Policy · MS · Psychiatry, PharmacyMedium impact

Buprenorphine

Effective date
Not stated in the notice
Identified
Jun 20, 2026

Summary

Subutex (buprenorphine) sublingual tablets require prior authorization under BCBSMS policy L.5.01.475 and may be considered medically necessary for patients 16 years of age or older being treated for opioid dependence, with a treatment plan that includes counseling and/or psychosocial support. Sublocade (buprenorphine solution) is considered not medically necessary on all Blue Cross and Blue Shield of Mississippi formularies because there are other formulary alternatives covered by the Plan. The May 26, 2026 review updated the indications description for Sublocade (buprenorphine extended-release) injection, left the policy statements unchanged, and removed ICD-9 diagnosis codes from the code reference.

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What to do

Action · 10 steps
01REQUIREMENTS: Get prior authorization for Subutex (buprenorphine) sublingual tablets.
02Initial criteria: the patient is 16 years of age or older, is being treated for opioid dependence, has a treatment plan that includes counseling and/or psychosocial support, and is either in induction therapy, in maintenance treatment because of naloxone intolerance, or in maintenance treatment because she is pregnant or breastfeeding.
03The patient must not have any FDA-labeled contraindication, and the dosage must be within program quantity limits based on FDA-labeled dosing.
04Initial approval length is 12 months.
05Renewal requires prior approval through the BCBSMS PA process and continued meeting of the initial criteria, an evaluation for illicit drug use (including problematic alcohol use) within the initiation treatment period, a treatment plan with a taper strategy as appropriate, compliance with all elements of the treatment plan, and prescriber confirmation of no concurrent opioid use or diversion, such as review of the Prescription Drug Monitoring Program or urine drug screening.
06Renewal approval length is 12 months.
07Subutex used for treating pain, other substance dependence, or concurrent treatment of pain and opioid dependence is considered investigational.
08BCBSMS determines medication trials and adherence from pharmacy claims data over the preceding 12 months, and medical records listing previously prescribed medications will not be sufficient.
09The use of samples by an individual will not be considered current or stable therapy.
10Services related to delivery or administration of a self-administered drug are not covered for State Health Plan participants.

Codes mentioned

F11.20F11.220F11.221F11.222F11.229F11.23F11.24F11.250F11.251F11.259F11.281F11.282F11.288F11.29

Original notice

Buprenorphine
bcbsms.com · Always check the source before changing claims.
View original ↗

Related policy hubs

Blue Cross & Blue Shield of Mississippi policiesMS policy changesPsychiatryPharmacyCode F11.20Code F11.220Code F11.221Code F11.222Code F11.229Code F11.23Code F11.24Code F11.250Code F11.251Code F11.259Code F11.281Code F11.282Code F11.288Code F11.29

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