SUBOXONE/VIVITROL WEBINAR - Educational Training tool concerning the Non-Methadone Medication Assisted Treatment Policy that is Effective on 1/1/12
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SUBOXONE®/VIVITROL®
WEBINAR
Educational Training tool concerning the Non-Methadone
Medication Assisted Treatment Policy that is Effective on
1/1/12
WEBINAR INTRODUCTIONS Cynthia Parsons- Program Manager Behavioral Health – WV Medicaid Lisa Richardson- Trainer/Consultant-APS Healthcare Christy Gallagher –Trainer/Consultant-APS Healthcare
MEDICAL NECESSITY Medical Necessity is services and supplies that are: (1) appropriate and necessary for the symptoms, diagnosis or treatment of an illness; (2) provided for the diagnosis or direct care of an illness; (3) within the standards of good practice; (4) not primarily for the convenience of the plan member or provider; and (5) the most appropriate level of care that can be safely provided
SUBOXONE®/VIVITROL®-
MEDICATION
PHARMACOLOGIC MANAGEMENT
PROCEDURE CODE: 90862
SERVICE UNIT: Event
SERVICE LIMITS: Two events per month with registration
PAYMENT LIMITS: Members may not receive Psychiatric Diagnostic Interview Evaluation (procedure code 90801) or
Mental Health Comprehensive Medication Services (procedure code H2010) on the same day 90862 is provided.
PRIOR AUTHORIZATION: Yes, Refer to APS Health Care Utilization Management Guidelines.
DEFINITION:
Pharmacologic Management services include prescription, use, and review of medication by a psychiatrist/physician,
with no more than minimal medical psychotherapy.
DOCUMENTATION:
The psychiatrist/physician must complete and sign an activity note describing the service provided. The
documentation must include: consumer’s response to medication, reason for encounter (scheduled/unscheduled),
place of service and date of service.VIVITROL®-PHARMACY
PRIOR AUTHORIZATION CRITERIA
Requests for Vivitrol® will be authorized if the following criteria are met:
Vivitrol® is prescribed for the treatment of alcohol and/or opioid
dependence for patients who are able to abstain from alcohol in an outpatient
setting prior to initiation of treatment or for prevention of relapse to opioid
dependence following opioid detoxification.
The patient is opioid free at the time of administration (for treatment of
alcohol dependence or prevention of relapse to opioid dependence) and is not in
acute opiate withdrawal. (Patient cannot have failed the naloxone challenge test
or have positive urine screen opioids.VIVITROL®-PHARMACY
PRIOR AUTHORIZATION CRITERIA-
CONT
The patient is 18 years of age or older
There is documentation of availability of counseling as well as other supports such as
NA/AA groups that offer support during treatment for alcohol dependence or prevention
of relapse of opioid dependence.
The patient does not have liver failure or hepatitis
The patient has not previously exhibited hypersensivity to naltrexone ne, PLG,
carboxymethylcellulose, or any other components of the diluent..SUBOXONE® –PHARMACY
PRIOR AUTHORIZATION
CRITERIA
Prior Authorization request must be made in writing by an approved
prescriber on the designated PA form by fax or electronic submission.
Prescribed by a licensed physician who qualifies fro a waiver under the
Drug Addiction Treatment ACT (DATA ) and has notified the Center
for Substance Abuse Treatment of the intention to treat addiction
patients and has been assigned a DEA (X) number.SUBOXONE® –PHARMACY
PRIOR AUTHORIZATION
CRITERIA-CONT.
Prescribed by a WV Medicaid enrolled provider (enrolled directly ,
enrolled with WV Medicaid HMO, employed by a facility that is
enrolled that is enrolled with WV Medicaid) who certifies he/she is
treating the patient and billing WV Medicaid for this service.SUBOXONE® –PHARMACY
PRIOR AUTHORIZATION
CRITERIA-CONT.
Confirmed diagnosis of opioid dependence.
o Diagnosis Code Required
The Patient is at least 16 years old
Subutex® will only be approved during pregnancy
Maximum initial dose is 24mg per day for a maximum of a 60 day
period.SUBOXONE® –PHARMACY
PRIOR AUTHORIZATION
CRITERIA-CONT.
Maximum initial dose is 24 mg per day for a maximum of a 60 day period;
initial dosing is limited to once per lifetime.
Maximum maintenance dose is 16mg per day (tablet splitting for lower doses is
required, when appropriate)
Early refills are not permitted, including replacement of lost or stolen medicationSUBOXONE® –PHARMACY
PRIOR AUTHORIZATION
CRITERIA-CONT.
PA is limited to:
o Drug naïve patients : 7 day supply per prescription for a 3-month period, then;
o If compliant with treatment plan: 14-day supply per prescription for a 6 month
period, then;
o If compliant with a treatment plan: 30 day supply per prescription per 6 month
interval.
Combination with benzodiazepines, hypnotics, and opioids (including
tramadol®) will be denied.SUBOXONE® –PHARMACY
PRIOR AUTHORIZATION
CRITERIA-CONT.
Attestation from prescriber that the Board of Pharmacy Prescription Drug
Monitoring Program database has been reviewed for other drug use including
benzodiazepine, sedative/hypnotics and opioids .
Patient must be warned about the dangers of ingesting concurrent sedating
medicationsNON-METHADONE MEDICATION
ASSISTED TREATMENT
Non-Methadone Medication Assisted Treatment Guidelines: West Virginia Medicaid covers the
following non-Methadone Medication Assisted Treatment Services: Individuals seeking opioid addiction
treatment with Subutex/Suboxone® or alcohol addiction treatment with Vivitrol®, must be evaluated by
an enrolled physician as specified below, before beginning medication assisted treatment. An initial
evaluation may be completed by a staff member other than the physician however no medication may be
prescribed until the physician has completed their evaluation. Members seeking treatment with
Subutex/Suboxone® must have a diagnosis of opioid dependence or Members seeking treatment with
Vivitrol®, must have a diagnosis of alcohol and/or opioid dependence. All physicians agree to adhere to
the Coordination of Care Agreement (see Attachment 1) which will be signed by the member, the treating
physician and the treating therapist. If a change of physician or therapist takes place, a new agreement
must be signed. This agreement must be placed in the member’s record and updated annually.NON-METHADONE
MEDICATION ASSISTED
TREATMENT-CONT.
Physician Requirements: The physician responsible for prescribing and monitoring
the member’s treatment must have a degree as a Medical Doctor and/or Doctor of
Osteopathic Medicine. Must be licensed, board certified and in good standing in the
state of West Virginia. Requirements for the Drug Addiction Treatment Act of 2000
(DATA 2000) must be met by the physician unless indicated by Substance Abuse
Mental Health Services Administration (SAMHSA). Physicians must be included on
the DATA Physician Locator. The physician must be an enrolled WV Medicaid
provider.NON-METHADONE
MEDICATION ASSISTED
TREATMENT-CONT.
Therapy Services are face to face structured interventions (e.g. psychotherapy, specialty therapies, family preservation interventions,
etc.) designed to improve a member’s cognitive processing and/or functional abilities. The intent of this type of intervention is to
focus on the dynamics of a member’s problems (i.e., the cause of the member’s dysfunctions; resolution of
intrapsychic/interpersonal conflicts; eliciting change in behavior patterns; and to produce change toward identifiable goals.)
Interventions are grounded in a specific and identifiable theoretical base that provides framework for assessing change. This service
may be provided in a variety of outpatient settings, but in all settings the service must be provided on a scheduled basis by
designated staff.
Any therapeutic intervention applied must be performed by a minimum of a Master’s Level Therapist using generally accepted
practice of therapies recognized by national accrediting bodies of psychology, psychiatry, counseling, and social work. Alcohol
Drug Counselor (ADC) or higher level accreditation in addictions and Psychologists may be treating therapists for individuals
utilizing Subutex/Suboxone® or Vivitrol®. In addition, LCSW, LICSW, LPC or therapists with Master’s Level Degrees and 2+
years of documented experience in the substance abuse field may provide therapy services.NON-METHADONE
MEDICATION ASSISTED
TREATMENT-CONT.
Documentation: Documentation must include a Master Service Plan and an individual
therapeutic intervention plan which expands on the more generalized objectives in the Master
Service Plan. The plan must also include a schedule detailing when therapy services are to be
provided.
For each therapy service, there must be an activity note describing each service or activity
provided; the relationship of the service or activity to a specific objective(s) (based upon Medical
Necessity) in the therapy plan, the actual intervention utilized and the outcome (consumer’s
response) of the service. The documentation must include the signature and credentials of the
staff providing the service, place of service, date of service.NON-METHADONE
MEDICATION ASSISTED
TREATMENT-CONT.
Required Timelines: Members will attend a minimum of four (4) hours of
therapeutic services per month. The four hours must contain a minimum of one
(1) hour individual professional therapy session per month. Frequency of
therapeutic services may increase based upon medical necessity.
Reviews: Prescribing providers are subject to retrospective review of cases to
verify compliance with requirements identified in this document. Reviews will be
conducted by BMS or its designee.NON-METHADONE
MEDICATION ASSISTED
TREATMENT-CONT.
Drug Screens: A minimum of two (2) random urine drug screens per month are required. A record of the results of these screens must
be maintained in the member’s record. The drug screen must test for, at a minimum, the following substances:
Opiates
Oxycodone
Methadone
Buprenorphine
Benzodiazepines
PCP/LSD
Amphetamine
Methamphetamine
AlcoholQUESTIONS/FAQ’S If you have any questions please email them to Cynthia Parsons and with these questions we will build the FAQ’s that will be permanently posted to the HCBS Webpage as shown on a previous slide.
CONTACTS Christy Gallaher, APS Trainer/Consultant at 304-533-8862 Lisa Richards, APS Trainer/Consultant at 304-550-8893 Emily Proctor, APS, 304-343-9663 Cynthia Parsons –Program Manager Behavioral Health –WV Medicaid email- Cynthia.A.Parsons@wv.gov
WEBSITES OF INTEREST http://www.dhhr.wv.gov/bms/Pages/default.aspx http://www.dhhr.wv.gov/bms/Documents/Ch502.pdf http://www.dhhr.wv.gov/bms/Documents/Ch503%2011- 18.pdf http://www.dhhr.wv.gov/bms/hcbs/Pages/default.aspx
THANK YOU AND WE LOOK FORWARD TO WORKING WITH ALL OF YOU
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