Q9992 Buprenorphine xr over 100 mgInjection, buprenorphine extended-release (sublocade), greater than 100 mg
Q9992 payment limit: $2,060.132 per Greater than 100 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
12496-0300-01 Sublocade, Indivior Inc.: 1 billing unit per package (1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 1 SOLUTION in 1 SYRINGE)Status E: excluded from the PFS by regulation.
26 of 31 payer prior-auth lists that name Q9992 require prior authorization or set conditions: Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Humana | Humana Healthy Horizons | FL | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Florida Prior Authorization and Notification List | |
| Humana | Humana Healthy Horizons | OK | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List | |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 | |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 | |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 | |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 | |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 | |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 | |
| UnitedHealthcare Community Plan | AHCCCS Complete Care (ACC) | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Developmentally Disabled | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Long Term Care | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Indiana Hoosier Care Connect | IN | prior auth required | Oct 1, 2026 | Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Mississippi CHIP | MS | prior auth required | Apr 1, 2025 | Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025 | |
| UnitedHealthcare Community Plan | Pennsylvania CHIP | PA | prior auth required | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026 | |
| UnitedHealthcare Community Plan | Pennsylvania Medicaid | PA | prior auth required | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026 | |
| UnitedHealthcare Community Plan | Texas STAR+PLUS | TX | prior auth required | Jul 1, 2018 | Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p |
Q9992 appears in 5 coverage policies from Aetna, BlueCross BlueShield of South Carolina, Centene, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Extended-Release Buprenorphine Injectables (0910) | covered if criteria are met | Dec 30, 2025 | payer document |
| BlueCross BlueShield of South Carolina | Extended-Release Injectable (Sublocade) (CAM 201) | listed, no stance | Jul 1, 2026 | payer document |
| Centene | Buprenorphine Injection (Sublocade, Brixadi) (CP.PHAR.289) | covered if criteria are met | Feb 1, 2026 | payer document |
| UnitedHealthcare | Buprenorphine (Brixadi® & Sublocade®) (2025D0057S) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Buprenorphine (Brixadi® & Sublocade®) (CS2026D0057Y) | listed, no stance | Apr 1, 2026 | payer document |
Prior authorization required or conditional in IN.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.