Does Q9991 require prior authorization?

Yes, Q9991 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for Q9991?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`Q9991`, Injection, buprenorphine extended-release (sublocade), less than or equal to

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium 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.

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.

9 Active Policies

FLORIDA_BLUE-FLBLUE-EXTENDED-RELEASE-INJECTABLE-SUBLOCADE-E4AEFF4261, Extended-Release Injectable (Sublocade)

POINT32HEALTH-MDMNG-13896, Sublocade (buprenorphine extendedrelease)

MULTI

BCBSNJ-DRUGS-145-189E498D85, Probuphine (Buprenorphine) Implant for Subdermal Administration and Sublocade (Buprenorphine Extended-Release) Injection for Subcutaneous Use

HEALTHNET_OR-HNOR-BUPRENORPHINE-INJECTION-SUBLOCADE-BRIXADI-CP-PHAR-289-34EFA0E96E, Buprenorphine Injection (Sublocade, Brixadi); CP.PHAR.289

UMR-POL-UMR-buprenorphine, Buprenorphine (Brixadi & Sublocade)

SUREST-POL-SUREST-buprenorphine, Buprenorphine (Brixadi & Sublocade)

UHC-COMM-MD-BUPRENORPHINE-BRIXADI-SUBLOCADE-COMMUNIT-234162D9D9, Buprenorphine (Brixadi & Sublocade) – Community Plan Medical Benefit Drug Policy

UHC-EXCH-MD-BUPRENORPHINE-BRIXADI-SUBLOCADE-INDIVIDU-16AF5CF040, Buprenorphine (Brixadi & Sublocade) – Individual Exchange Medical Benefit Drug Policy

UHC-POL-buprenorphine, Buprenorphine (Brixadi & Sublocade)

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Q9991, Injection, buprenorphine extended-release (sublocade), less than or equal to