This site is intended for US healthcare providers

  • INSUPPORT(TM) Logo
Specialty Pharmacy
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

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 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's information has been routed to a specialty pharmacy from INSUPPORT™, the Final Benefit Summary will also provide instructions for the HCP on which network specialty pharmacy to send the patient's SUBLOCADE prescription for fulfilment.

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 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 4: Send patient prescription to specialty pharmacy

Send the patient's prescription to the specialty pharmacy identified in the "Prescribing Routing Information" section of the Final Benefit Summary in order to initiate the specialty pharmacy process.

Going directly to a specialty pharmacy?

For HCPs who choose to refer patients directly to a specialty pharmacy, the specialty pharmacy will verify and provide the insurance provider's PA requirements and forms, if applicable, as part of their benefit investigation process. The specialty pharmacy will follow up with the insurance provider until the outcome of the PA is determined.

INSUPPORT™ can provide contact information for network specialty pharmacies.

Step 3: Review options for a denied PA

If the patient's 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

DOWNLOAD PDF

View a Sample Letter of Medical Necessity

DOWNLOAD PDF

Information about possible next steps when a PA is denied

WATCH VIDEO
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 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's information has been routed to a specialty pharmacy from INSUPPORT™, the Final Benefit Summary will also provide instructions for the HCP on which network specialty pharmacy to send the patient's SUBLOCADE prescription for fulfilment.

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 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 Benefit Summary from INSUPPORT™

DOWNLOAD PDF

Step 2: Send patient prescription to specialty pharmacy

Send the patient's prescription to the specialty pharmacy identified in the "Prescribing Routing Information" section of the Final Benefit Summary in order to initiate the specialty pharmacy process.

Going directly to a specialty pharmacy?

For patients not enrolled in INSUPPORT™, HCPs will need to complete an intake form for their chosen network specialty pharmacy. The completed intake form with required signatures(s) along with a valid prescription must be faxed to the specialty pharmacy to start the specialty pharmacy process.

The specialty pharmacy will verify the insurance provider requirements as part of their benefit investigation and determine if a PA is required.

INSUPPORT™ can provide contact information for network specialty pharmacies.

Have questions?

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

FIND AN FRS IN YOUR AREA

X
John Doe
INSUPPORT™ Field Reimbursement Specialist
Phone: 1 (888) 888-8888
FAQs
Does a new INSUPPORT Patient Enrollment Form have to be completed for a new prescription or for every refill from the specialty pharmacy?

No. Hub enrollment or a new benefit investigation is not necessary unless the patient's insurance has changed. Once the HCP has learned which network specialty pharmacy is selected by the patient's insurance provider, the HCP can send the next prescription directly to that specialty pharmacy.

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.