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TRICARE East Outpatient Opioid and SUD Request Form

Humana Military uses this two-page form for TRICARE East authorization of outpatient or ambulatory opioid and substance use disorder treatment, including medication-assisted treatment. The servicing provider documents psychiatric and medical diagnoses, current medications and prescribers, substance use history with last use, support group participation, the induction date, prescribed medication and dose, and the CPT-coded services requested.

Who completes it

The servicing provider, an MD, DO, PhD, clinical social worker (CCSW) or certified psychiatric nurse specialist, completes the form with the referring provider's details, including any military hospital or clinic, and signs it.

Submitting and payment

How to submit it
Use the Humana Military self-service portal for the TRICARE referral and attach the form; fax it only if internet access is not available.
Who pays
Services are requested by CPT code with the modality and number of units, alongside the medication's dosage interval and quantity per day.

Good to know

  • The form asks whether there was a failed attempt at medication-assisted treatment in the past 12 months, and whether the patient is pregnant or breastfeeding.
  • If there was non-compliance or a gap in therapy since the initial authorization, the provider marks it and attaches an explanation.
  • Substance use history lists each substance with method of ingestion, amount, frequency and date of last use, plus community support group attendance and whether the patient has a sponsor.
  • The form asks whether the patient is an active duty service member. Current version XPBB0326-A, March 2026.

Get the official form

Download the current version from the source each time; forms change without notice.

Outpatient/Ambulatory Opiate and SUD Treatment Request Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can be the servicing provider on the TRICARE outpatient SUD form?

The form's provider type options are MD, DO, PhD, clinical social worker (CCSW) and certified psychiatric nurse specialist (CPNS). The servicing provider lists specialty, sub-specialty and TIN or NPI, and the referring provider or military hospital or clinic is recorded separately.

What medication details does the opioid treatment request need?

The induction date, prescription name, anticipated completion date, dosage and interval, and quantity per day, along with the CPT codes, services and units requested. The provider also marks any failed medication-assisted treatment in the past 12 months, gaps in therapy, and pregnancy or breastfeeding.

How is the TRICARE outpatient SUD form submitted?

Through the self-service portal at HumanaMilitary.com as part of the TRICARE referral. Humana Military accepts a faxed form only when internet access is not available, and the provider signs to confirm the beneficiary can actively participate in the program.