Billing and Coding Guide - INSUPPORT
Healthcare settings and pharmacies that order and dispense SUBLOCADE must be certified in this program and comply with the REMS requirements. • See accompanying full Prescribing Information, including BOXED WARNING and Medication Guide, or go to www.SUBLOCADE.com. P-BAG-US-00851 EXPIRY December 2022 • • • • • • • • •
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PATIENT AUTHORIZATION AND CONSENT - …
www.insupport.comPage 3 of 3 P-BAG-US-00223 EXPIRY February 2020 Fax INSUPPORT: 844-814-0669 X Patient Signature Date By signing below, • I authorize 1. my treatment provider (including his/her staff and any affiliated group practices), 2. the health insurer(s) listed on my enrollment form, and 3. the specialty pharmacy that dispenses SUBLOCADE to me to …
STEPS TO BUY-AND-BILL - insupport.com
www.insupport.comP-BAG-US-00236 EXPIRY February 2020. See accompanying full Prescribing Information, including . BOXED WARNING. or go to sublocade.com. What is the buy-and-bill process?