BUPRENORPHINE

BUPRENORPHINE (13310M)

buprenorphine 400 microgram sublingual tablet, 7
13310M
Body System:
Manner of administration:Sublingual
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16009)

Indication: Opioid dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 28 # of repeats: 5 DPMQ: $36.30 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Subutex

BUPRENORPHINE (13320C)

buprenorphine 100 mg/0.5 mL modified release injection, 0.5 mL syringe
13320C
Body System:
Manner of administration:Injection
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16050)

Indication: Opioid dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 5 DPMQ: $379.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Sublocade

BUPRENORPHINE (13327K)

buprenorphine 300 mg/1.5 mL modified release injection, 1.5 mL syringe
13327K
Body System:
Manner of administration:Injection
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16050)

Indication: Opioid dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 5 DPMQ: $379.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Sublocade

BUPRENORPHINE (13336X)

buprenorphine 2 mg sublingual tablet, 7
13336X
Body System:
Manner of administration:Sublingual
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16009)

Indication: Opioid dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 12 Max qty units: 84 # of repeats: 5 DPMQ: $120.22 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Subutex

BUPRENORPHINE (13337Y)

buprenorphine 8 mg sublingual tablet, 7
13337Y
Body System:
Manner of administration:Sublingual
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16009)

Indication: Opioid dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 16 Max qty units: 112 # of repeats: 5 DPMQ: $413.58 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Subutex