201908-120367
2019
CVS Caremark
Self-Funded
Substance Abuse/ Addiction
Pharmacy/ Prescription Drugs
Step Therapy
Upheld
Case Summary
This is a patient with opioid use disorder and chronic pain (dorsalgia and neuropathy). The patient was prescribed Zubsolv 5.7/1.4 milligram (mg) tablets at a dose of one and one-half tab daily as maintenance medication to assist in the substance use disorder treatment of opioid use disorder; however, this medication failed to address cravings and post-acute withdrawal symptoms of the opioid use disorder. A previous trial of Suboxone Film resulted in more effective control of craving and withdrawal symptoms. Moreover, the patient has not been compliant with the treatment plan while taking Zubsolv in that he has used opioids affirmed with a urine drug screen. The health plan's determination is upheld. The health plan formulary has the availability of Suboxone tablets which provides the same benefit of Suboxone Film. The documentation does not indicate that the patient has tried and failed Suboxone Tablets. Thus, Suboxone is available for this patient as a different formulation with the likelihood of equivalent benefit, as cited in the references below.
The patient has not reported trial and failed treatment with this formulary alternative. Medical necessity for the requested non-formulary medication is not met in keeping with the instruction for this review and is not consistent with the scientific literature or published guidelines that supports the use of the formulary alternative in this case. This answer is also consistent with prevailing standards of medical practice.