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Prior Authorization
INSUPPORT can research prior authorization (PA) requirements

Completing a PA

Some insurance providers may require a PA to grant a patient coverage for SUBLOCADE™ (buprenorphine extended-release) injection, for subcutaneous use (CIII). INSUPPORT™ can research and communicate PA requirements from a patient's insurance provider.


Is a PA required?


Step 1: Review the Preliminary Benefit Summary instructions

INSUPPORT™ can provide insurance provider-specific PA forms to an HCP office. The patient's healthcare provider must complete and submit the PA form to the patient's insurance provider.

Once the required PA forms and/or documentation are submitted to the patient's insurance provider, INSUPPORT™ can track the status of the PA request until an outcome is determined by the patient's insurance provider.

Information about obtaining a PA

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Step 2: Learn PA outcome

Once a coverage determination has been made, the patient's insurance provider will communicate the outcome of the PA request, and INSUPPORT™ will follow up with the HCP office on next steps or with the Final Benefit Summary.

Step 3: Review the Final Benefit Summary

If enrolled in INSUPPORT™ Hub Services, INSUPPORT™ will provide a written Final Benefit Summary to the HCP office and the patient, outlining the key coverage information and out-of-pocket estimates for SUBLOCADE. The document includes details about the patient's enrollment status in the INSUPPORT™ Copay Assistance Program, if applicable. If the patient opted into a Patient Benefit Summary call at the time of enrollment, an INSUPPORT™ Case Manager will contact the patient to review the coverage information reported by the patient's insurance provider, and explain the next steps.

The Final Benefit Summary will be faxed to you or can be reviewed on the INSUPPORT™ Provider Portal, based on your communication preference.

View a Sample Final Benefit Summary from INSUPPORT™

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Step 3: Review options for a denied PA

If a PA request is denied by the patient's insurance provider, the patient may have options.

Review the information submitted to the patient's insurance provider for accuracy. PA requests may be denied if the information provided was incomplete or inaccurate. Check for errors and resubmit the information to the patient's insurance provider if there were inaccuracies in the original PA. INSUPPORT™ can identify and communicate appeal requirements from the patient's insurance provider to assist in the appeals process on the patient's behalf.

Complete a Letter of Appeal or Letter of Medical Necessity. You may submit a Letter of Medical Necessity or Letter of Appeal to provide further information about the patient's treatment and request that their coverage for SUBLOCADE be re-evaluated.

View a Sample Letter of Appeal

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View a Sample Letter of Medical Necessity

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Information about possible next steps when a PA is denied

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Request a peer-to-peer discussion

An HCP may request a peer-to-peer discussion with a representative from the insurance provider to discuss the patient and the rationale for requesting a certain medication.

INSUPPORT™ can track the status of a PA appeals decision by the patient's insurance provider.

Step 1: Review the Final Benefit Summary

If enrolled in INSUPPORT™ Hub Services, INSUPPORT™ will provide a written Final Benefit Summary to the HCP office and the patient, outlining the key coverage information and out-of-pocket estimates for SUBLOCADE. The document includes details about the patient's enrollment status in the INSUPPORT™ Copay Assistance Program, if applicable. If the patient opted into a Patient Benefit Summary call at the time of enrollment, an INSUPPORT™ Case Manager will contact the patient to review the coverage information reported by the patient's insurance provider, and explain the next steps.

The Final Benefit Summary will be faxed to you or can be reviewed on the INSUPPORT™ Provider Portal based on your communication preference.

View a Sample Final Benefit Summary from INSUPPORT™

DOWNLOAD PDF

Step 2: Order SUBLOCADE through a specialty distributor

Create an account with a network specialty distributor who carries SUBLOCADE. Many specialty distributors offer online, email, and phone ordering.

Information about setting up an account with specialty distributors

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Contact information for network specialty distributors that carry SUBLOCADE is available on the Resources and Tools page.

Have questions?

Receive information from a local Field Reimbursement Specialist (FRS) regarding your access and reimbursement questions.

FIND AN FRS IN YOUR AREA

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John Doe
INSUPPORT™ Field Reimbursement Specialist
Phone: 1 (888) 888-8888
FAQs
Do I have to renew a PA once the patient's health insurance plan has approved it?

Often, insurance providers require re-authorization for the patient after a certain period of time. If the patient is enrolled in INSUPPORT™ Hub Services, INSUPPORT™ will notify you 21 days in advance of expiry of the current authorization and provide re-authorization requirements communicated by the patient's insurance provider. If the patient is not enrolled in INSUPPORT™, you may contact the patient's health insurance provider for information about re-authorization requirements.

Is there any additional information that the health insurance provider may require to determine a PA for the patient?

Each health insurance plan has its own PA requirements. If the patient is enrolled in INSUPPORT™ Hub Services, INSUPPORT™ will inform you of any requirements communicated by the patient's insurance provider on the Preliminary Benefit Summary. If the patient is not enrolled in INSUPPORT™, you may contact the patient's health insurance provider for information about PA requirements.