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HealthPartners

Coverage criteria policies

Buprenorphine injectable (Sublocade)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Sublocade requires prior authorization from HealthPartners Pharmacy Administration.

Coverage

Sublocade is generally covered subject to the indications listed below and per your plan documents.

Initial Approvals

  1. Sublocade is reserved for patients unable to use oral therapy. This includes patients unable or unwilling to use oral therapy, and patients for whom the provider has concerns about diversion; and
  2. Sublocade is prescribed within the FDA approved dosing regimen.

Authorizations will be provided for 12 months.

Reauthorizations

  1. Provider attests that the patient has been seen and evaluated within the previous 12 months, and this medication continues to be medical necessary; and
  2. Sublocade is prescribed within the FDA approved dosing regimen.

Reauthorizations will be provided for 12 months.

Definitions

Sublocade contains buprenorphine, a partial opioid agonist, and is indicated for the treatment of moderate to severe opioid use disorder in patients who have initiated treatment with a transmucosal buprenorphine-containing product, followed by dose adjustment for a minimum of 7 days.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:

HCPCS

Codes

Description

C9399

Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) (do not use on or after 7/1/2018)

J3490

Unclassified drugs (do not use on or after 7/1/2018)

Q9991

Injection, buprenorphine extended-release (Sublocade), less than or equal to 100 mg (Effective 7/1/2018)

Q9992

Injection, buprenorphine extended-release (sublocade), greater than 100 mg (Effective 7/1/2018)

NDC

Codes

Description

12496030001

Sublocade 300 MG/1.5ML SOSY

12496010001

Sublocade 100 MG/0.5ML SOSY

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Sublocade (prescribing information). North Chesterfield, VA, Indivior Inc., March 2018.

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Policy activity

  • 05/07/2018 - Date of origin
  • 05/07/2018 - Effective date

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