Q9991 — Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of counseling and psychosocial support as part of a complete treatment plan (per FDA labeling recommendation).
- Initial therapy: Documentation that the patient is being treated for opioid use disorder.
- Initial therapy (if not on maintenance buprenorphine): documentation of a test dose of buprenorphine establishing that buprenorphine is tolerated without precipitated withdrawal.
- Initial therapy (alternative): documentation that the patient is already being treated with buprenorphine (if applicable).
Key Coverage Criteria
- Continuation of therapy: Brixadi or Sublocade dosing is in accordance with the U.S. Food and Drug Administration approved labeling.
- Continuation authorization will be for no more than 12 months.
- Indicated diagnoses (listed in Applicable Codes): ICD-10 F11.20, F11.21, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29 (opioid dependence/opioid use disorder codes).
- Buprenorphine extended-release injection (e.g., Brixadi, Sublocade) is proven for the treatment of moderate to severe opioid use disorder in patients who meet all of the following criteria.
- Initial therapy: Patient is being treated for opioid use disorder.
- Initial therapy: Either (a) patient is not currently receiving maintenance buprenorphine treatment AND patient has received a test dose of buprenorphine to establish that buprenorphine is tolerated without precipitated withdrawal; OR (b) patient is already being treated with buprenorphine.
3 Active Policies
UHC-POL-buprenorphine — Buprenorphine (Brixadi & Sublocade)
UMR-POL-UMR-buprenorphine — Buprenorphine (Brixadi & Sublocade)
SUREST-POL-SUREST-buprenorphine — Buprenorphine (Brixadi & Sublocade)
Related Codes
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