[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-278210-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-278210-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","sample-letter-of-medical-necessity-for-sublocade-buprenorphine-extended-release","Sample Letter of Medical Necessity for SUBLOCADE - (buprenorphine extended-release)","","Sample letter provides healthcare providers with a structured template to request insurance coverage for SUBLOCADE (buprenorphine extended-release). The letter explains medical necessity by summarizing the patient’s diagnosis, prior and current opioid use disorder treatment, and clinical rationale supporting SUBLOCADE. It includes submission guidance for prior authorization and documentation, and incorporates key prescribing-indication details plus required patient-specific fields, physician attestation, and safety/warning references.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/letters/","Letters",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/sample-letter-of-medical-necessity-for-sublocade-buprenorphine-extended-release/278210/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/sample-letter-of-medical-necessity-for-sublocade-buprenorphine-extended-release/278210.png","ImageObject",442,249,{"name":42,"@type":43},"Chumphorn","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-27","2026-09-15",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",17,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information must a letter of medical necessity for SUBLOCADE include?","Question",{"text":63,"@type":64},"The letter should explain why SUBLOCADE is medically necessary, supported by patient-specific information such as medical records, clinical treatment history, and relevant prescribing and supporting information.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How can the SUBLOCADE coverage request be submitted?",{"text":68,"@type":64},"Submission may be made with a prior authorization request, a claim form, or as part of a response for additional documentation, and it should be on practice letterhead signed by the treating physician.",{"name":70,"@type":61,"acceptedAnswer":71},"Why is intravenous administration a concern for SUBLOCADE?",{"text":72,"@type":64},"The template highlights risk of serious harm or death with intravenous administration, because SUBLOCADE forms a solid mass on contact with body fluids and may cause occlusion and thrombo-embolic events, including life-threatening pulmonary emboli.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},278210,1789508230,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},"Forms",40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":115,"slug":116},18,30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":114,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":30},2336475401981,"https://ap-avatar.wpscdn.com/avatar/22000c94efd8d5204d?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786935347598174694","SAMPLE LETTER OF MEDICAL NECESSITY FOR SUBLOCADE ® (buprenorphine extended-release )  \nA letter of medical necessity may be requested by payers to support coverage for SUBLOCADE. Within this letter, there should be an explanation of why SUBLOCADE is medically necessary for the patient, and it should contain information that supports the need for SUBLOCADE for the patient, such as medical records, clinical treatment history, Prescribing Information, Medication Guide, and supporting literature. Submission of the letter may bein conjunction with a prior authorization request, with a claim form, or as a part of a response for additional documentation. Be sure to submit the letter of medical necessity on the practice letterhead, have it signed by the treating physician, and include patient-specific information.  \nThis is a sample letter of medical necessity. This sample letter is intended to be an example for healthcare providers who have prescribed SUBLOCADE and who would like to request insurance coverage of SUBLOCADE fora patient. The [blue] text should be customized to provide specific information about your patient. The patient’s insurance company may require additional information, and the sample letter may not include all topics required by the insurance company.  \nThis sample letter is for demonstration purposes only. It provides an example of the type of information that maybe required when submitting for or appealing a coverage determination. Use of this template or the information in this template does not guarantee reimbursement or coverage. It is not intended to be a substitute for or to influence the independent clinical decision of the prescribing healthcare professional.  \nINDICATION  \nSUBLOCADE is for moderate to severe opioid use disorder in those who have initiated treatment with a dose of transmucosal buprenorphine or are being treated with buprenorphine and should include counseling and psychosocial support.  \nSELECT IMPORTANT SAFETY INFORMATION  \nWARNING: RISK OF SERIOUS HARM OR DEATH WITH INTRAVENOUS ADMINISTRATION; SUBLOCADE RISK EVALUATION AND MITIGATION STRATEGY  \n• Serious harm or death could result if administered intravenously. SUBLOCADE forms a solid mass upon contact with body fluids and may cause occlusion, local tissue damage, and thrombo-embolicevents, including life threatening pulmonary emboli, if administered intravenously.  \n• Because of the risk of serious harm or death that could result from intravenous self-administration, SUBLOCADE is only available through a restricted program called the SUBLOCADE REMS Program. Healthcare settings and pharmacies that order and dispense SUBLOCADE must be certified in this program and comply with the REMS requirements.  \nPlease see Important Safety Information on pages 4-7 and the full  Prescribing  Information, including BOXED WARNING, and  Medication Guide or go to [SUBLOCADEHCP.com](SUBLOCADEHCP.com. For REMS information)[. For REMS information](SUBLOCADEHCP.com. For REMS information), [visit ](visit www.SUBLOCADEREMS.com)[www.SUBLOCADEREMS.com](visit www.SUBLOCADEREMS.com).  \nP-BAG-US-01676v2 May 2026 Page 1 of 7  \n[Date]  \n[Medical or Pharmacy Director][Insurance Plan or PBM][Address]  \n[City, State ZIP Code]  \nSAMPLE LETTER ONLY  \nSubject: Letter of Medical Necessity for SUBLOCADE® (buprenorphine extended-release) injection  \nInsured: [Patient Name]; Policy Number: [Policy Number]; Group Number: [Group Number]  \nDear [Medicare or Pharmacy Director’s Name]:  \nI am writing on behalf of my patient,[First Name][Last Name], to request that [Insurance Plan/PBM Name] approve coverage for [Mr/Ms/Mrs/other title][Last Name]’s treatment with SUBLOCADE® (buprenorphine extended-release) for their [first/second dose]. SUBLOCADE is indicated for the treatment of moderate to severe opioid use disorder as part of a complete treatment program that includes counseling and psychosocial support. Per the package insert, the second injection of SUBLOCADE may be administered","cbCaihYQ2CtZb9P5","https://ap.wps.com/l/cbCaihYQ2CtZb9P5","pdf",156467,7,"English","# Indication and Safety Overview\n## Indication\n## Important Safety Information and REMS\n# Template Header and Subject Line\n## Recipient and Insured Details\n# Letter Sections\n## Patient Medical Overview and History\n## Rationale for Treatment\n## Treatment Plan","[{\"question\":\"What information must a letter of medical necessity for SUBLOCADE include?\",\"answer\":\"The letter should explain why SUBLOCADE is medically necessary, supported by patient-specific information such as medical records, clinical treatment history, and relevant prescribing and supporting information.\"},{\"question\":\"How can the SUBLOCADE coverage request be submitted?\",\"answer\":\"Submission may be made with a prior authorization request, a claim form, or as part of a response for additional documentation, and it should be on practice letterhead signed by the treating physician.\"},{\"question\":\"Why is intravenous administration a concern for SUBLOCADE?\",\"answer\":\"The template highlights risk of serious harm or death with intravenous administration, because SUBLOCADE forms a solid mass on contact with body fluids and may cause occlusion and thrombo-embolic events, including life-threatening pulmonary emboli.\"}]","Sample Letter of Medical Necessity for SUBLOCADE - (buprenorphine extended-release) | PDF"]