Opioid use disorder drug requires new prior authorization beginning July 1

Sublocade™, which is approved for treatment of opioid use disorder, will require providers to get prior authorization before using the medication beginning July 1, 2018. This medication is paid under the plan’s medical benefit.

The U.S. Food and Drug Administration (FDA) recently approved Sublocade™ as a treatment for moderate-to-severe opioid use disorder in adult patients who have initiated treatment with a transmucosal (absorbed through mucus membrane) buprenorphine-containing product. 

This new program provides a consistent approach for medical management of the long-acting buprenorphine products. UnitedHealthcare already requires prior authorization review for Probuphine® under the medical benefit. 

For dates of service before July 1, 2018

UnitedHealthcare encourages providers to request pre-service coverage reviews so they can check whether a medication is covered before providing services.

  • Clinical coverage reviews can help to avoid starting a patient on therapy that may later be denied due to lack of medical necessity.

  • If providers request a pre-service coverage review, they must wait for our determination before rendering the service. 

For dates of service on or after July 1, 2018

UnitedHealthcare will require notification/prior authorization for this medication. 

  • If care providers administer this medication without first completing the notification/prior authorization process, the claim may be denied. 

  • Members can’t be billed for services denied due to failure to complete the notification/prior authorization process. 

The notification/prior authorization requirement for this medication will apply to all UnitedHealthcare commercial plans including affiliate plans such as UnitedHealthcare of the Mid-Atlantic, UnitedHealthcare Oxford, Neighborhood Health Partnership and UnitedHealthcare of the River Valley. Timing of pre-service review/prior authorization depends on the urgency of the request. Urgent requests fall within 72 hours. If the request is not urgent, pre-service review/prior authorization will fall within state guidelines.