Adjunctive Medications

The Health and Recovery Services Administration (HRSA)/DSHS in collaboration with DBHR/DSHS has recognized three new medications in the treatment of addictions.  These medications must be prescribed by a physician in conjunction with state certified chemical dependency treatment and require a completed authorization form for Medicaid payment.  For information about Suboxone (Buprenorphine), Campral (Acamprosate), or ReVia (Naltrexone) Authorization forms, see these sites:

• DSHS HRSA Memorandum #06-75 (Revised 11/2006, Effective 10/1/06) 
  http://fortress.wa.gov/dshs/maa/download/memos/2006Memos/06-75%20Drug%20Oct%20reissued.pdf
  
  (In the HRSA Memorandum, search for either Suboxone, Campral, ReVia, or Vivitrol to find these medications within the Memo.
   
• DSHS HRSA Numbered Memorandum web page http://fortress.wa.gov/dshs/maa/download/Numberedmemos.html
  
  (See #07-61 re Revia/Naltrexone)
   
• HRSA DSHS Pharmacy Information Page
  http://fortress.wa.gov/dshs/maa/pharmacy/
   
• DSHS Authorization Forms can be found on the DSHS Forms website:
  1. Buprenorphine/Suboxone Authorization Form (DSHS 13-720)
  2. Campral Authorization Form (DSHS 13-749)
  3. ReVia Authorization Form (DSHS 13-677)
  4. Buprenorphine/Suboxone Exemption Request Form (DSHS 13-750)
  5. Vivitrol IM Physician Prior Authorization Form (DSHS 13-791) [PDF] or [Word]

For more information about these medications:

• SAMHSA's Buprenorphine-Frequently Asked Questions: http://buprenorphine.samhsa.gov/bwns_locator/index.html.  This site includes the Buprenorphine Physician Locator.
• To learn more about ReVia (Naltrexone) visit this SAMHSA web site:  http://dpt.samhsa.gov/medications/naltrexone.aspx.
• To learn more about Campral, visit this Forest Laboratories web site:  http://www.campral.com.
• To learn more about Vivitrol IM, visit the Vivitrol® IM Information web site at http://www.vivitrol.com/. 

If you have any questions about Adjunctive Medications, call Deb Cummins at 360-725-3716, or e-mail cummida@dshs.wa.gov.

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