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.

SourceLink

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 mg

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