CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A
Extended‑release buprenorphine injections (Sublocade, Brixadi) for moderate to severe opioid use disorder
Policy governs prior authorization and medical necessity criteria for Sublocade (buprenorphine extended‑release) and Brixadi (buprenorphine extended‑release) for treatment of moderate to severe opioid use disorder in members (Pharmacy scope: Medicaid; Medical scope: Medicaid, Commercial, MMP). It defines initial authorization (6 months), continuation (12 months), dosing/administration limits, and associated HCPCS/J‑codes.
Policy Summary
PayerNeighborhood Health Plan of Rhode Island
PolicyExtended‑release buprenorphine injections (Sublocade, Brixadi) for moderate to severe opioid use disorder
Policy CodePolicy N/A
Change TypeReviewed/References updated
Effective DateSep 1, 2018
Next Review Date
Key ActionAuthorization required for initial therapy (up to 6 months) and continuation therapy (up to 12 months) per criteria; document counseling/psychosocial support participation and meet product-specific induction requirements.
POLICY UPDATE CHANGES
Reviewed multiple times through 04/2025 with references updated (prescribing information dated 2025).
2Products covered (Sublocade, Brixadi)
6 monthsInitial authorization duration
12 monthsContinuation authorization duration
300 mgSublocade monthly maximum