Clinical UM Guideline

This document addresses the use of drug testing (using urine, blood, saliva, sweat or hair) in the outpatient setting for adherence monitoring in the following situations:

• controlled substance use as part of the management of chronic pain
• individuals undergoing treatment for opioid addiction and/or substance use disorder.

Note: This document does not address the use of urine drug testing in the following circumstances:

• Emergency department testing, including for the detection of potential overdose or poisoning.
• Screening for commercial drivers licensing, or any other job-related testing.
• State/legally mandated drug testing.

Note: Drug testing or screening for employment issues may be addressed in the member certificate. Please refer to the member’s benefits for further information.

Note: Sample validation is a method that is sometimes needed to assure source integrity. Quality assurance to assure sample integrity is part of expected clinical laboratory test management.

Note: For more information about pain biomarker urine testing, please see:

• LAB.00048 Pain Management Biomarker Analysis

Medically Necessary:

Presumptive urine drug testing (UDT) to verify compliance with treatment, identify undisclosed drug use or abuse, or evaluate aberrant* behavior is considered medically necessary up to 24 times per year, beginning at the start of treatment, as part of a monitoring program tailored to the unique needs of individuals who are:

1. Receiving treatment for chronic pain with prescription opioid or other potentially abused medications; or
2. Undergoing treatment for, or monitoring for relapse of, opioid addiction or substance use disorder.

Presumptive urine drug testing is also considered medically necessary for the following:

1. To assess an individual when clinical evaluation suggests use of non-prescribed medications or illegal substances; or
2. On initial entrance into a pain management program or substance use disorder recovery program.

Definitive urine drug testing to verify compliance with treatment, identify undisclosed drug use or abuse, or evaluate aberrant* behavior is considered medically necessary up to 24 times per year, beginning at the start of treatment, as part of a monitoring program tailored to the unique needs of individuals whose requests meet criteria both A and B below:

1. Testing indications- either 1 or 2 below must be present:
   1. Receiving treatment for chronic pain with prescription opioid or other potentially abused medications; or
   2. Undergoing treatment for, or monitoring for relapse of, opioid addiction or substance use disorder;
      and
2. Testing scenarios- either 1 or 2 below have been met:
   1. Definitive testing following prior presumptive testing:
      1. The presumptive urine drug testing was done for a medically necessary reason; and
      2. The presumptive test was positive for an illegal drug (for example, but not limited to methamphetamine or cocaine), positive for a prescription drug with abuse potential which was not prescribed, or negative for prescribed medications; and
         1. The specific definitive test(s) ordered are supported by documented rationale for each test ordered; and
         2. Clinical documentation reflects how the results of the test(s) will be used to guide clinical care;
            or
   2. Definitive testing without prior presumptive testing:
      1. Presumptive urine drug tests are not available for the drug in question (examples may include, opioids and their metabolites such as fentanyl, meperidine, tramadol, and tapentadol, muscle relaxants and their metabolites such as carisoprodol, synthetic cannabinoids and their metabolites, as well as cathinones [“Bath Salts”] and their metabolites); and
      2. The specific definitive test(s) ordered are supported by documented rationale for each test ordered; and
      3. Clinical documentation reflects how the results of the test(s) will be used to guide clinical care.

*Aberrant behavior includes, but is not limited to, lost prescriptions, repeated requests for early refills, prescriptions from multiple providers, unauthorized dose escalation, and apparent intoxication.

Note: Each definitive test request must be based on the tested individual’s diagnosis, substance use patterns, results of presumptive testing and other clinical factors documented in the medical record. Community patterns of illicit drug use must not be imputed to an individual without a documented rationale. UDT monitoring of prescribed drugs is not a clinically appropriate way to estimate the therapeutic effectiveness of prescribed drugs. Definitive testing for more than 7 classes of drugs (including metabolites) would be unusual for most individuals. For a list of drug classes, see the Appendix below.

The use of blood samples as an alternative to urine for drug testing is considered medically necessary when the use of urine is not feasible (for example, when an individual has advanced kidney failure).

Not Medically Necessary:

The use of presumptive urine drug testing is considered not medically necessary when the criteria above are not met.

The use of definitive urine drug testing is considered not medically necessary when the criteria above are not met.

The use of presumptive or definitive testing panels is considered not medically necessary unless all components of the panel have been determined to be medically necessary based on the criteria above. However, individual components of a panel may be considered medically necessary when criteria above are met.

The use of blood samples for drug testing is considered not medically necessary in all other circumstances, including when the criteria above have not been met.

The use of saliva, sweat, or hair samples for drug testing is considered not medically necessary in all circumstances.

The use of any of the following for definitive drug testing of urine or blood samples is considered not medically necessary in all circumstances:

1. Reflex testing; or
2. Standing orders; or
3. Blanket orders.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:
For the following procedure codes, or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Urine Drug Testing (UDT)

The use of UDT in individuals with a substance use disorder or undergoing opioid treatment for chronic pain conditions is common and serves several purposes. According to the American College of Physicians (ACP, 2008), the reasons for UDT include:

• Enhancing patient care.
• Providing objective documentation of an individual’s compliance with the treatment plan and opioid agreement.
• Reducing the risk of an unrecognized drug misuse/abuse problem.
• Serving as an adjunct to self-reports of drug/substance use.
• Proving or disproving abuse/addiction of illicit or non-prescribed licit drugs.
• Justifying continuation of chronic opioid analgesic therapy in individuals who adhere to the treatment plan and have acceptable urine drug tests.
• Providing a rationale to change the treatment plan in individuals with unacceptable urine drug tests and justifying referral to addiction specialists.

The American Pain Society (APS) and American Academy of Pain Medicine (AAPM) joint guidelines panel released their opioid treatment guidelines titled Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non-cancer Pain in 2009 (Chou, 2009). In this document, the AAPM addressed the monitoring of controlled substances use via UDT as part of a chronic opioid treatment (COT) program. The guideline section on monitoring (Section 5) states:

5.1 Clinicians should reassess patients on COT periodically and as warranted by changing circumstances. Monitoring should include documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies (strong recommendation, low-quality evidence).
5.2 In patients on COT who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to the COT plan of care (strong recommendation, low-quality evidence).
5.3 In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care (weak recommendation, low-quality evidence). Clinicians should periodically reassess all patients on COT. Regular monitoring of patients once COT is initiated is critical because therapeutic risks and benefits do not remain static.

In 2017, the American Society of Addition Medicine (ASAM) published a document titled Appropriate Use of Drug Testing in Clinical Addiction Medicine (Jarvis, 2017). The ASAM provided an array of recommendations related to UDT and other drug testing procedures. The document included the following recommendations regarding presumptive and definitive testing:

• Presumptive testing should be a routine part of initial and ongoing patient assessment.
• Presumptive testing should be used when it is a priority to have more immediate (although less accurate) results.
• Definitive testing techniques should be used whenever a provider wants to detect specific substances not identified by presumptive methods, quantify levels of the substance present, and refine the accuracy of the results.
• Definitive testing should be used when the results inform clinical decisions with major clinical or non-clinical implications for the patient (e.g. treatment transition, changes in medication therapies, changes in legal status).
• If a patient disputes the findings of a presumptive test, a definitive test should be done.
• When ordering a definitive test, providers should advise the testing laboratory if the presence of any particular substance or group of substances is suspected or expected.

The ASAM document also addressed testing frequency:

• For people in addiction treatment, frequency of testing should be dictated by patient acuity and level of care.
• Providers should look to tests’ detection capabilities and windows of detection to determine the frequency of testing.
• Providers should understand that increasing the frequency of testing increases the likelihood of detection of substance use, but there is insufficient evidence that increasing the frequency of drug testing has an effect on substance use itself.
• Drug testing should be scheduled more frequently at the beginning of treatment; test frequency should be decreased as recovery progresses.
• During the initial phase of treatment, drug testing should be done at least weekly. When possible, testing should occur on a random schedule.
• When a patient is stable in treatment, drug testing should be done at least monthly. Individual consideration may be given for less frequent testing if a patient is in stable recovery. When possible, testing should occur on a random schedule.

Finally, ASAM recommended the following related to UDT:

• Urine should be considered the most well-established and well-supported biological matrix for presumptive detection of substance use in a clinical setting.
• Urine should be considered the best established matrix for POCTs.*

*Point of care tests.

In 2019 ASAM published a document titled Public Policy Statement on the Ethical Use of Drug Testing in the Practice of Addiction Medicine. This document contained important statements regarding the ethical use of drug testing, including:

2. Drug testing should be used only when clinically necessary. Tests should be selected based on an individualized clinical assessment of the patient and performed after informed consent whenever possible.
   1. Clinicians should document the rationale for the drug tests they order and document the clinical decisions they make based on those tests. The use of drug screening panels that test for multiple classes of drugs or multiple compounds within a drug class is a pragmatic approach that can be helpful especially in primary care practices. Drug testing panels may be pragmatic for new patients in addiction treatment programs, but follow-up testing should be individualized to the patient's history, needs, initial test results, and drugs commonly used in the patient’s geographic location and peer group. (This may not be possible where an external entity such as a governmental agency requires routine testing drug panels to be performed periodically on a set time frame.)
   2. The use of drug testing panels which apply to every patient at every testing time regardless of the patient’s individual clinical history and needs may not be appropriate because this can result in over- or underutilization of diagnostic services.
3. Presumptive testing should be a routine part of initial and ongoing patient assessment. Definitive testing may be used to detect specific substances not identified by presumptive methods and to refine the accuracy of the test results. Definitive testing may be used when the results are needed to inform clinical decisions where the results will alter the care plan.
   1. Clinical decisions may be made based on drug test results or on patient self-report of use. Patient self-report of negative use is often unreliable and positive self-report is complicated by purchasing of illicit drugs that are not consistent or reliable in their components.
   2. It is inappropriate to order definitive testing for all analytes in every drug test conducted on a patient and to do so repeatedly, without regard to the results from previous tests or the patient’s overall response to addiction treatment interventions. Ethical use of drug testing requires that the scope of the analyte panel and the frequency of testing be justified by the patient’s clinical status and the ordering clinician’s need for information.

The exact frequency and pattern of urine drug screening is individualized based on the risk for abuse. The Washington State Agency Medical Directors' Group (AMGD) published an Interagency Guideline on opioid dosing for pain. This guideline and related expert commentary support low-risk individuals having 1 UDTs up to once per year, moderate-risk up to 2 UDTs per year, high-risk individuals up to 3-4 UDTs per year. Individuals exhibiting aberrant behaviors should be tested at the time of the office visit. The American Pain Society guidelines (Chou, 2009) state that for individuals at low risk for adverse outcomes, quarterly or semi-annual monitoring is sufficient. For very high-risk individuals, weekly monitoring may be reasonable. However, the AMGD states that there is insufficient evidence to support this recommendation. This observation is reiterated in a review article by McMillin and colleagues (2013), where they comment that there is a lack of detailed guidelines addressing the appropriate use of DUT to support chronic pain management. The ASAM white paper does not recommend an upper limit for testing. However, in the context of abuse, the McMillin review recommends testing no less than once weekly at first then once monthly once abstinence is established. Such limits apply to both presumptive and definitive testing. There is insufficient clinical reasoning to support the use of definitive testing at a frequency greater than for presumptive testing.

The American College of Obstetricians and Gynecologists (ACOG) recommends a screening interview for substance use be completed on the first prenatal visit as part of comprehensive obstetric care (2017). ACOG recommends following up with UDT to detect or confirm suspected substance use when the individual consents.

The risk for abuse may be measured using standard tools, such as the Screener and Opioid Assessment for Patients with Pain (SOAPP^®; PainEdu.org, 2013) and the Revised Opioid Risk Tool (ORT-R or ORT-OUD; Cheatle, 2019). These tools aid clinicians in assessing the suitability of long-term opioid therapy for individuals with chronic pain, and help differentiate those who may require more or less clinician monitoring while on long-term opioid therapy. The SOAPP tool is available for free and can be accessed at https://www.mcstap.com/docs/SOAPP-5.pdf . Four different versions are available to allow for varying levels of evaluation. All versions of the SOAPP tool may be self-administered at or prior to an office visit or can be completed as part of an interview with a nurse, physician or psychologist. The ORT was developed by Webster (2005) and was modified by Cheatle in 2019 (ORT-R/ORT-OUD). Like the SOAPP, it may be self-administered or used as part of a clinical evaluation. The ORT-R/ORT-OUD can be accessed for free at https://nida.nih.gov/nidamed-medical-health-professionals/screening-tools-resources/opioid-risk-tool-oud-ort-oud.

Presumptive versus Definitive Testing

Presumptive testing is intended to identify the use or non-use of a drug or class of drugs. Definitive tests are more specific and allow for the detection of specific drugs or metabolites of interest. In most cases presumptive testing is used because it is quick, fairly accurate, and easily accessible in a wide variety of settings. Definitive testing may be needed when presumptive results alone are not sufficient to guide clinical care. However, in most situations, the identification or quantification of a specific drug of interest may not result in a different treatment plan. Definitive testing, particularly when performed repeatedly, must be clinically meaningful and documentation must support the specific necessity of each definitive assay performed as well as how that test result will affect clinical management.

Drug Testing of Blood, Saliva, Sweat, or Hair Samples

The 2017 ASAM recommendations (Jarvis, 2017) address the use of alternate sample matrices in the following statements:

• The relevance of blood testing in addiction treatment is limited mostly to emergency situations where there is a need to assess intoxication or impairment.
• No statements about the appropriateness of breath testing were endorsed by the Expert Panel.
• Oral fluid testing is appropriate for presumptive detection of substance use in addiction treatment settings.
• There is insufficient evidence to support the use of sweat testing in addiction treatment. More research is needed before sweat testing can be recommended over urine testing in clinical settings.
• Hair testing in addiction treatment can detect long-term patterns of use. Routine use of hair testing is not appropriate for addiction treatment.

These recommendations support the use of oral fluid testing for presumptive detection; however, the evidence cited in the guideline discussion consists of low-quality references including reviews and a study that evaluates the volume of oral fluid needed for an appropriate sample. The recommendations reference a Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) on ethical issues in relation to alcohol abuse and other substance use disorders. ACOG recommends routine screening with validated questionnaires or conversations and does not recommend routine laboratory testing of biologic samples for substance use disorders (ACOG, 2015). ASAM does suggest that oral fluid testing might be useful in some cases, but further research on which specific drugs and metabolites oral fluid testing might best detect is recommended (Jarvis, 2017).

The U.S. Department of Health and Human Services (DHHS) Substance Abuse and Mental Health Services Administration (SAMHSA) has published two documents that address drug testing for individuals in primary care and substance abuse disorder treatment programs (SAMHSA, 2012, 2014). In these documents, the benefits and drawbacks of drug testing using alternative sample sources is evaluated. However, in their primary care document (2012) SAMHSA clarifies that urine is the most widely used and studied source. This was reiterated in their 2014 Treatment Improvement Protocol (TIP) for opioid addiction programs.

The use of samples other than urine, including blood, hair, saliva, and sweat, is not recommended by most authoritative organizations that provide guidance on drug testing, including the ACP (Kirschner, 2014), the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM, Chou, 2010) and the Washington State Agency Medical Directors' Group (AMGD, 2015). The American Society of Transplantation recommends urine drug testing in individuals when needed to identify abuse and diversion and to guide treatment (Jowsey-Gregoire, 2022). The use of UDT is not possible in some circumstances. Individuals with renal failure who are on dialysis or those with bladder control impairments may be unable to provide a sample. In these limited circumstances, UDT may need to be replaced by blood tests.

There is growing support for the use of saliva testing, especially in cases where a urine sample is unobtainable, when such results may be unreliable, or when there is a history of urine sample tampering. However, as noted above, there is little evidentiary support for this approach.

In summary, the use of blood, hair, saliva, and sweat is not widely recommended and these matrices each have significant drawbacks to their use when compared to UDT.

Testing Panels

Many commercial laboratories market multi-test panels for the presence of various prescription and illicit drugs and their metabolites. While the use of some individual tests included in these test panels may be reasonable under specific circumstances, the use of all the tests within a panel is rarely justified unless there is clinical evidence that an individual has used or been exposed to multiple substances, and knowledge of such exposure provides information that leads to meaningful impact on treatment.

Reflex testing, Standing orders, and Blanket orders

The use of reflex testing, standing orders, and blanket orders for definitive testing of urine or blood samples is contrary to good clinical practice, which is based on clinical decision-making as to the necessity of specific laboratory tests. In the case of these types of tests, they are done in the absence of the requisite clinical decision-making process and are based solely on automated processes devoid of clinical judgment. They do not meet the requirement for there to be documentation of a specific rationale for each ordered test and documentation of how the test will be used to modify treatment for the tested individual.

Blanket order: A test request that is not for a specific individual, but it is an identical order for all individuals in a clinician’s practice. Such orders do not take the clinical situation of each individual into consideration at the time of request, or during each visit.

Definitive testing: A type of testing that is more specific than presumptive testing, and allows for the detection of specific drugs or metabolites.

Drug class: Drugs, medications or illicit substances (including metabolites of each member of the class) that share similar essential aspects of their chemical structure and at least one similar mechanism of action (i.e., bind to the same biological target). For example, opioids interact with one or more opioid receptor. Drugs associated with substance use disorders, including alcohol and inhalants, are thought to directly activate the brain reward system as a common mode of action.

Drug diversion: Prescription drugs provided to an individual other than the one to whom the drugs were prescribed.

Drug testing panel: A type of test that involves tests for more than one type of drug and may test for a pre-defined set of drug classes or metabolites of specific drugs or drug classes.

Member-specific profile: This term refers to the specific characteristics of an individual being treated for chronic pain or an individual undergoing treatment for opioid addiction and substance use disorder, which may be used to help guide treatment. These characteristics may include current and past alcohol and drug use patterns and clinical findings such as slurred speech, hallucinations or pin-point pupils that tend to be specific to a drug or drug class. Use of member-specific profiles assist in guiding the selection of the specific tests for drugs and their metabolites.

Planned testing: Testing being conducted at a time previously scheduled and known to the individual being tested.

Presumptive testing: A type of testing that is intended to identify the use or non-use of a drug or general class of drugs.

Random testing: Testing being conducted at a time not previously scheduled and not known to the individual being tested.

Reflex Testing: A laboratory test that is performed "reflexively" after an initial or presumptive test result suggests the need for further diagnostic information. This type of testing is not based on a specific clinical situation and provider's order, but is built into the testing process. Testing performed as a step necessary to complete the request of physician responsible for a members care and provided by an order is not considered reflex testing.

Standing order: A test request for a specific individual representing: 1) repetitive testing to monitor a condition or disease, or 2) individualized orders for repetitive automatic testing for certain individuals for pre-determined tests based on historical use, risk, and community trend patient profiles. Definitive drug testing standing orders are not consistent with ordering laboratory testing based upon clinical findings, nor are they sensitive to the individual’s history of drug use and community patterns of drug use.

Testing panel: A type of laboratory procedure where multiple tests are automatically run on a single sample to detect the presence of a variety of substances or class of substances.

Peer Reviewed Publications:

1. Cheatle MD, Compton PA, Dhingra L, et al. Development of the revised opioid risk tool to predict opioid use disorder in patients with chronic nonmalignant pain. J Pain. 2019; 20(7):842-851.
2. Christo PJ, Manchikanti L. Ruan X, et al. Urine drug testing in chronic pain. Pain Physician. 2011; 14(2):123-143.
3. Owen GT, Burton AW, Schade CM, Passik S. Urine drug testing: current recommendations and best practices. Pain Physician. 2012; 15(3 Suppl):ES119-ES133.
4. Melanson SE. The utility of immunoassays for urine drug testing. Clin Lab Med. 2012; 32(3):429-447.
5. Melanson SE, Ptolemy AS, Wasan AD. Optimizing urine drug testing for monitoring medication compliance in pain management. Pain Med. 2013; 14(12):1813-1820.
6. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005; 6(6):432-442.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Obstetricians and Gynecologists (ACOG). Committee opinion.
   • Committee Opinion No. 633: Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2015; 125(6):1529-1537. Reaffirmed 2021.
   • Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017; 130(2):e81-e94. Reaffirmed 2021.
2. American Society of Addiction Medicine (ASAM).
   • The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med. 2020; 14(2S Suppl 1):1-91. Erratum in: J Addict Med. 2020; 14(3):267.
   • Public Policy Statement on the Ethical Use of Drug Testing in the Practice of Addiction Medicine. April 3, 2019. Available at: https://www.asam.org/docs/default-source/public-policy-statements/2019-ethical-use-of-drug-testing-in-the-practice-of-addiction-medicine.pdf?sfvrsn=75bb4bc2_4#search="drug testing". Accessed on October 14, 2023.
3. Chou R, Fanciullo GJ, Fine PG, et al.; American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009. 10(2):113-130.
4. Centers of Medicare and Medicaid, Complying with documentation requirements for laboratory services. August 2018. Available at: Complying with Laboratory Services Documentation Requirements (cms.gov). Accessed on October 14, 2023.
5. Jarvis M, Williams J, Hurford M, et al. Appropriate Use of Drug Testing in Clinical Addiction Medicine. J Addict Med. 2017; 11(3):163-173.
6. Jowsey-Gregoire S, Jannetto PJ, Jesse MT, et al. Substance use screening in transplant populations: Recommendations from a consensus workgroup. Transplant Rev (Orlando). 2022; 36(2):100694.
7. Manchikanti L, Kaye AM, Knezevic NN, et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 2017; 20(2S):S3-S92.
8. McMillin GA, Slawson MH, Marin SJ, Johnson-Davis KL. Demystifying analytical approaches for urine drug testing to evaluate medication adherence in chronic pain management. J Pain Palliat Care Pharmacother. 2013; 27(4):322-339.
9. New Hampshire Medical Society. New Hampshire Opioid Prescribing Risk. Opioid risk screening tools and articles. 2016. Available at: Opioid Risk Screening - New Hampshire Medical Society (nhms.org). Accessed on October 14, 2023.
10. PainEDU.org. Screener and Opioid Assessment for Patients with Pain- Revised (SOAPP® -R) . Available at: https://d1li5256ypm7oi.cloudfront.net/colospine/2016/08/SOAPP-R-Screener-and-Opioid-Assessment-for-Patients-with-Pain-Revised-160816-57b258fc9a277.pdf . Accessed on October 14, 2023.
11. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration (SAMHSA).
    • Clinical Drug Testing in Primary Care. Technical Assistance Publication Series 32. 2012. Available at: https://store.samhsa.gov/sites/default/files/d7/priv/sma12-4668.pdf. Accessed on October 14, 2023.
    • Federal Guidelines for Opioid Treatment Programs. January 2015. https://store.samhsa.gov/sites/default/files/d7/priv/pep15-fedguideotp.pdf. Accessed on October 14, 2023.
    • Medication-assisted treatment for opioid addiction in opioid treatment programs. A treatment improvement protocol TIP 43. 2014 Available at: https://store.samhsa.gov/sites/default/files/d7/priv/sma12-4108.pdf. Accessed on October 14, 2023.
    • Medications for Opioid use Disorder. A treatment improvement protocol TIP 63. Updated 2021. Available at: https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP21-02-01-002.pdf. Accessed on October 14, 2023.
12. Washington State Agency Medical Directors' Group. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy. 2015 Update. Available at: https://agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf. Accessed on October 14, 2023.

Buprenorphine
Naloxone
Suboxone^®

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

The following table lists drugs and their metabolites in drug classes based on Generic Product Index level 2 classifications (GPI2), the FDA’s National Drug Classifications (NDC), PubChem classifications, and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), but does not include every drug and metabolite. Metabolites not listed in the table should be categorized with their parent drug.

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.