Step 1: Collect any out-of-pocket costs from the patient
You may contact the patient's insurance provider to understand what portion of the medication cost should be collected from the patient. For patients enrolled in "Benefit Coverage Information" with INSUPPORT, INSUPPORT will provide a benefit summary to the healthcare provider (HCP) and the patient detailing the patient's estimated out-of-pocket responsibility for SUBLOCADE® (buprenorphine extended-release injection, for subcutaneous use (CIII) as reported by the patient's insurance provider, if applicable.
Step 2: Submit the claim form
Following administration of SUBLOCADE to the patient, submit a claim to the patient's insurance provider. INSUPPORT can provide you with billing and coding information.
Step 3: Reimbursement
If the claim is approved, the patient's insurance provider should provide payment to the HCP office.
Addressing claim denials
A: Identify the reason for the claim denial
If your claim is denied by the patient's insurance provider, you will be notified of the denial reason either by INSUPPORT or by the insurance provider.
Some of the common reasons for denial include:
- Incomplete or inaccurate information
- Lack of prior authorization
- Diagnosis and procedure coding errors and omissions
- Insufficient medical necessity
B: Fix any errors and provide additional documentation
If required, verify coding and other information provided is complete and accurate. You may also submit a Letter of Medical Necessity to the patient's insurance provider, if required by the insurer.
View Sample Letter of Medical Necessity†
*The INSUPPORT Copay Assistance Program is valid ONLY for patients with private insurance who are prescribed SUBLOCADE for on‑label use. Patients with government insurance are not eligible for the Copay Assistance Program, including, but not limited to, Medicare, Medicaid, Medigap, VA, DoD, TRICARE, CHAMPVA, or any other federally or state funded government assisted program. Other restrictions apply.
†This sample is intended for informational purposes only and not for direct use as a Letter of Medical Necessity.
For more information, please refer to the Terms and Conditions for the INSUPPORT Copay Assistance Program for SUBLOCADE.
What is the difference between the J-code and the Q-code?
J and Q‑codes are HCPCS Level II codes that are assigned by CMS to report drugs and biologics. Q‑codes may be assigned and implemented on a quarterly basis while J‑codes are assigned and implemented on an annual basis.
Are insurance payers reimbursing for the Q‑codes?
Yes, in general, all payer types provide reimbursement for correct claims submitted with Q‑codes.
Payers have differing coverage criteria, but in general, provide reimbursement for correct claims submitted with Q‑codes. You should check with individual payers for specific questions.
Do I need to complete the INSUPPORT Patient Enrollment Form again to receive Appeals Information for a denied claim?
For patients already enrolled in "Benefit Coverage Information" with INSUPPORT, appeals information can be provided, where applicable, and does not require a new enrollment. Please contact INSUPPORT for more information.