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 provide information on the PA process and/or PA requirements from a patient's insurance provider, when applicable.
For patients enrolled in Transition of Care Support, PA requirements for the new provider are detailed on the Final Benefit Summary.
Is a PA required?
Step 1: Review the PA Requirements
When applicable, INSUPPORT can provide insurer PA requirements to a healthcare provider (HCP) office. The patient's HCP must complete and submit any required PA form(s) to the patient's insurance provider.
Once the required PA forms and/or documentation are submitted to the patient's insurance provider, INSUPPORT can check the status of the PA request until an outcome is determined by the patient's insurance provider.
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
Following notification of the PA outcome from the patient's insurance provider, INSUPPORT will provide a written Final Benefit Summary to the HCP office, and to the patient if requested, detailing the patient's benefit coverage information for SUBLOCADE. The document also includes 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, answer any questions, and explain next steps.
For patients enrolled in Transition of Care Support that have coverage for SUBLOCADE, INSUPPORT will provide a copy of the Final Benefit Summary for the new site of care to the enrolling HCP and the new treatment provider. The enrolling HCP will also receive an appointment confirmation sheet that can be returned to INSUPPORT if an appointment has been coordinated with the new treatment provider on behalf of the patient. If the patient has opted-in to text reminders on the enrollment form, the patient can receive text reminders for an upcoming appointment or injection due date with the new provider.
Learn more about Transition of Care Support
View an annotated sample Final Benefit Summary from INSUPPORT*
Download PDF*These samples are intended for informational purposes only and not for direct use as benefit summary.
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. 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 SampleView a Sample Letter of Medical Necessity*
Download SampleRequest 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 check on the status of a PA appeal from the patient's insurance provider until a decision has been made.
*These samples are intended for informational purposes only and not for direct use as a Letter of Appeal or Letter of Medical Necessity
Step 1: Review the Final Benefit Summary
Following notification of the PA outcome from the patient's insurance provider, INSUPPORT will provide a written Final Benefit Summary to the healthcare provider (HCP) and to the patient if requested, detailing the patient's benefit coverage information for SUBLOCADE. The document also includes 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, answer any questions, and explain next steps.
For patients enrolled in Transition of Care Support that have coverage for SUBLOCADE, INSUPPORT will provide a copy of the Final Benefit Summary for the new site of care to the enrolling HCP and the new treatment provider. The enrolling HCP will also receive an appointment confirmation sheet that can be returned to INSUPPORT if an appointment has been coordinated with the new treatment provider on behalf of the patient. If the patient has opted-in to text reminders on the enrollment form, the patient can receive text reminders for an upcoming appointment or injection due date with the new provider.
Learn more about Transition of Care Support
See an annotated sample form now*
Download PDF*These samples are intended for informational purposes only and not for direct use as benefit summary.
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.