Skip to main content

This site is intended for US healthcare providers

INSUPPORT® Logo

Prior Authorization

INSUPPORT® can provide information on 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).

For patients enrolled in "Benefit Coverage Information" or "Transition of Care Support", INSUPPORT® can provide information on the PA process and/or PA requirements from a patient's insurance provider, when applicable. Regardless of whether patient information is provided from INSUPPORT® or directly from an HCP office, the specialty pharmacy receiving the patient's prescription will verify the patient's benefits as part of their benefit investigation process, and will provide the insurance provider's PA requirements and/or forms to the HCP office, if applicable.

Is a PA required?

Step 1: Complete and submit required PA information

When a PA is required by the patient's insurance provider, the specialty pharmacy will contact the HCP office regarding the authorization submission process and required information.

The patient's healthcare provider must complete and submit the PA form(s) to the patient's insurance provider.

Once the required PA forms are submitted to the patient's insurance provider, the specialty pharmacy will check the status of the PA request until an outcome is determined by the patient's insurance provider.

INSUPPORT® can provide contact information for network specialty pharmacies..

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 to the HCP office. The HCP may review the outcome to inform next steps.

Step 3: Communicate with the specialty pharmacy

If the PA is approved by the health insurance plan, the HCP may communicate the approval from the plan to the chosen specialty pharmacy. Once coverage is confirmed, the specialty pharmacy will contact the HCP to confirm the injection date and coordinate shipment of the medication.

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.

Some specialty pharmacies may provide support for an HCP office through the appeals process. For patients enrolled in "Benefit Coverage Information", INSUPPORT® can identify appeal requirements from the patient's insurance provider and provide information on the appeals process on behalf of the patient.

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
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.

Step 1: Communicate with the specialty pharmacy

Confirm the appointment and delivery date with the specialty pharmacy prior to each prescription fill.

INSUPPORT® can provide contact information for network specialty pharmacies.

Have questions?

Receive information from a local Patient Access Specialist (PAS) regarding your access and reimbursement questions.

FIND A PAS IN YOUR AREA

X
John Doe
INSUPPORT® Patient Access 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 "Benefit Coverage Information" with INSUPPORT®, 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 "Benefit Coverage Information" with INSUPPORT®, 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.