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HealthPartners

Coverage criteria policies

Buprenorphine (Probuphine)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

  • Prior authorization is required for buprenorphine implant (Probuphine).

Coverage

  • Buprenorphine implant (Probuphine) is generally covered1 subject to the indications listed below and per your plan documents.

Indications that are covered

  • Probuphine is reserved for FDA-approved indications (for patients stable on buprenorphine <= 8 mg per day), and with difficulty taking oral Suboxone as prescribed.

Indications that are not covered

  • Buprenorphine implant (Probuphine) is not covered for any additional indication.

Definitions

Probuphine is indicated for the maintenance treatment of opioid dependence in patients who have achieved and sustained prolonged clinical stability on low-to-moderate doses of a transmucosal buprenorphine-containing product (i.e., doses of no more than 8 mg per day of Subutex or Suboxone sublingual tablet equivalent or generic equivalent).

Probuphine should be used as part of a complete treatment program to include counseling and psychosocial support.

Probuphine is not appropriate for new entrants to treatment and patients who have not achieved and sustained prolonged clinical stability, while being maintained on buprenorphine 8 mg per day or less of a Subutex or Suboxone sublingual tablet equivalent or generic equivalent.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS

Codes

Description

J0570

Buprenorphine implant, 74.2mg

NDC

Codes

Description

58284-0100-14

Probuphine Implant Kit 74.2 MG IMPL

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

  • For in-network benefits to apply, item must be received from a contracted vendor or provider.

References

  1. Probuphine prescribing information. Braeburn Pharmaceuticals, Inc., Princeton, NJ. May 2016.

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Policy activity

  • 08/08/2016 - Date of origin
  • 01/01/2017 - Effective date
Review date
  • 08/2017

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