The SUBLOCADE® (buprenorphine extended-release) injection, for subcutaneous use, CIII, Patient Journey Map provides information on important steps for the acquisition of SUBLOCADE on behalf of patients.

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STEPS

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INFORMATION

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STEP 1
  |   Benefit Investigation

Conduct a benefit investigation of the patient’s insurance coverage, and obtain information on any prior authorization (PA) and appeals, if applicable.

Checklist

Close step1 checklist
  • Enroll your patient into the INSUPPORT® program to initiate the benefit investigation by submitting a completed Patient Enrollment Form to INSUPPORT via INSUPPORT PORTAL or fax at 844-814-0669
    • Appropriate eligible patients can enroll in the INSUPPORT Copay Assistance Program online at www.insupport.com/savings or by opting-in on the Patient Authorization Form
  • Pay close attention to fields that are commonly missed on the enrollment form:
    • Patient signature with date
    • Healthcare provider (HCP) signature with date
    • Diagnosis code(s)
    • Dosage

Tips

Close step1 tips
  • A patient signature and date are required to enroll in INSUPPORT®. Obtain patient signature during an office visit.
  • If you are sending the script directly to the specialty pharmacy (SP) and your patient has enrolled in the Copay Assistance Program, please include the patient's copay member identification number on the SP referral form.
  • Ensure you provide the SUBLOCADE Q-code to the payer if conducting your own benefit investigation
  • If you are unsure if the patient can acquire SUBLOCADE through an SP, INSUPPORT can conduct a benefit investigation to determine which of the network SPs is an option for the patient and which SP may be required by a plan

STEP 2
  |   Prior Authorization (PA)

If a PA is required by the health insurance plan, submit the required prior authorization information to the health insurance plan for review.

Checklist

Close step2 checklist
  • Submit the required Prior Authorization (PA) information to the health insurance plan (if a PA is required by the patient’s health insurance plan)
  • Ensure you accurately complete the PA and include all required supporting documentation, including:
    • Medical records and progress notes
    • Medication history
    • Drug screen
    • Site of administration information
    • Counseling appointment date list
    • Healthcare Common Procedure Coding System (HCPCS) code (Q-code)
    • National Drug Code (NDC)
    • Diagnosis code
    • HCP signature
  • Once a decision on the PA is provided by the health insurance plan, the HCP and patient may review the outcome to inform next steps
  • If the PA is approved by the health insurance plan, the HCP may forward any approval communication from the plan, along with the script for SUBLOCADE and patient’s copay member identification number (if applicable), to the chosen Specialty Pharmacy (SP)
  • If the PA is denied by the health insurance plan, the HCP and patient may consider exploring potential steps to appeal the decision with the health insurance plan

Tips

Close step2 tips
  • You can generally find the payer-specific Prior Authorization (PA) form on the payer website
  • If you are unable to locate the PA form, a local Patient Access Specialist (PAS) can help you locate it, along with the published payer policy, if applicable
  • INSUPPORT® can provide PA appeal information in the event that a PA is denied at the SP and an appeal is available from the patient’s health insurance plan
  • The healthcare provider (HCP) may complete any required PA forms to include both the SP and the HCP’s names and National Provider Identifiers (NPIs)
  • Document the start and end date of the PA. Consider setting a reminder in your calendar 30 days before the PA expires to renew
  • Determine if a new PA is required for dosage changes

STEP 3
  |  Acquisition

When using a pharmacy to obtain the medication, provide the required information to an in-network specialty pharmacy (SP) to begin the acquisition process.

Checklist

Close step3 checklist
  • Submit the prescription according to the payer’s instructions, or if not mandated by the plan, to one of the network SPs
  • If accessing via buy and bill, order SUBLOCADE from one of the network specialty distributors

Tips

Close step3 tips
  • If accessing via buy and bill, establish an account with one of the network specialty distributors several weeks before desired shipment date

STEP 4
  |  Shipment & Storage (SP Only)

Confirm the patient’s appointment and delivery date with the dispensing specialty pharmacy prior to each prescription fill, if applicable.

Checklist

Close step4 checklist
  • Determine if your office or facility can adequately and appropriately store SUBLOCADE
  • If so, schedule an appointment date that is after the delivery date
  • If your office is unable to store, schedule the appointment for the date of delivery
  • Remind the patient to answer the phone call from the SP
  • Administer SUBLOCADE according to the Prescribing Information (PI) (opens in a new tab), which includes instructions for use, including the administration of the medication

Tips

Close step4 tips
  • Provide the patient with the SP phone number. If they miss the call, the patient can call them back to give consent. If patient is in the office, the HCP and patient can call the SP together to have the patient give consent and schedule the shipment
  • If administering on the same date as the delivery, consider enrolling into the shipment carrier’s tracking options
    • Consider calling and requesting a tracking number from the SP the day before your delivery is scheduled

STEP 5
  |   Claim Submission

Submit a claim for reimbursement to the patient's health insurance plan for SUBLOCADE and/or the administration of the medication, depending on the acquisition method.

Checklist

Close step5 checklist
  • If accessing via an SP, bill the patient’s health insurance plan for the drug administration only†
  • If accessing via buy and bill, bill the patient’s health insurance plan for both the drug and administration†
  • Prior to submission, review the claim to ensure that it is complete and accurate†
    • If the patient is enrolled in INSUPPORT®, the Patient Access Specialist (PAS) can review the payer requirements with you

Tips

Close step5 tips
  • You may contact INSUPPORT® for information about the appeals process in the event of a denied claim

STEP 6
  |  Refill (SP ONLY)

Following the injection, consider next steps for the acquisition of the patient's subsequent SUBLOCADE prescription(s), if applicable.

Checklist

Close step6 checklist
  • Obtain refills for subsequent fills of SUBLOCADE
  • Following the injection, work with the SP to confirm a refill around 3 weeks before the PA expiration and the patient’s next appointment

Tips

Close step6 tips
  • Consider maintaining a calendar or spreadsheet to track patients and their refills
  • Note that PA timelines may vary by payer
  • Confirm that the PA is still active for the month 3 injection dose change, as this change may require a new prescription and PA
  • Report any known insurance or patient contact information changes to the SP

*This annotated sample is intended for informational purposes only and not for direct use as a Benefit Summary

†Indivior cannot guarantee payment of any claim. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual payers following the receipt of claims. For additional information, customers should consult with their payers for all relevant coding, reimbursement, and coverage requirements. It is the sole responsibility of the provider to select the proper code and ensure the accuracy of all claims used in seeking reimbursement. All services must be medically appropriate and properly supported in the patient medical record.

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