Washington prescribers request workers' compensation coverage of the buprenorphine transdermal patch (Butrans) with this one-page form sent to L&I's Drug Review Program. Chronic opioid therapy must already be authorized. The prescriber gives the indication, current and highest prior opioid doses, and two formulary opioids tried and failed with dates, doses and outcomes, or a medical contraindication to those trials.
The prescribing provider completes sections 1-4 and signs, with name and phone number in section 4.
Download the current version from the source each time; forms change without notice.
Buprenorphine Transdermal Patch Authorization Request Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Authorized chronic opioid therapy on the claim, the indication, the current and highest prior opioid doses, and at least two formulary opioids tried and failed with dates, doses and outcomes. If those trials were not done, explain the medical contraindication; otherwise the form directs you to use formulary opioids.
Fax it, with supporting medical documentation, to the Drug Review Program in L&I's Office of the Medical Director, using the number printed on the form. Send it before the prescription is filled, because drugs requiring prior authorization are not covered without approval.