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 Post subject: Insurance and costs
PostPosted: Tue Feb 21, 2017 9:47 am 
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So I have been on this med now for almost 3 weeks and love it. It's saved my life. Below is the text of a message I sent my insurance company if anyone had any similar experiences or feedback.


To whom it may concern at Anthem or Express Scripts:

I previously sent an email to Anthem via your mobile App and am not sure the agent who responded to me understood the questions or issues I am having regarding my medication. She quoted me regulations about pain medication which are not the problem. I am having a cost issue deciding what the most affordable medication or version of buprenorphine to be on long term.

I understand the pain pill limits etc etc but that is not the problem we are having. My doctor and the pharmacists and I all I am sure understand the DEA and FDA regs etc etc.

the problem is the costs and issue of trying to find out what is the affordable medication to place me on.

Here is the history this month.

I was on methadone for four years. As I am sure you can tell by my records I have been thru about 12 surgeries including 4 hip replacements. I was very dependent on hard to manage pain medication as a result of all the surgeries. My initial hip replacements did not work so they were finally recalled by J and J and new ones placed in me that are better. After four years of paying for my methadone out of pocket myself to the cost of $400 a month my doctors and counselors met and decided the suboxone type medication may be best for me longer term. It has less cardiac and hepatic issues. So we made the transition to switch going thru a very tough 3 month period where I lowered my methadone dose to be able to get on the buprenorphine.

a few weeks ago when my methadone dose was low enough to switch we started the buprenorphine/naloxone drug. Week one he placed me on the Non-generic strips (suboxone) as a trial for a week. When I went to pick them up the pharmacy said they were not on Anthem and Express scripts lists or formulary of approved drugs. At that time I paid out of pocket with a manufacturer coupon a cost of $92 to me. Not using insurance. At that time my pharmacist and doctor told me the generic tablets would be covered by anthem and were listed on the approved drug list. So a few days in they wrote me a script for the generic buprenorphine/naloxone tabs at the dose of 8mg/2mg. I take 16mg/4mg a day. So they have me take one 8/2 tablet sublingual in the morning and one 8/2 tablet in the afternoon. When I went to pick up this generic medication that is apparently on your list of approved meds it (for 14 tabs) was $123 with insurance for a week. That is more than I paid out of pocket for the strips the week prior that were NOT on your formulary. I was confused to say the least as to why I can buy a drug (suboxone) which is NOT generic and not on the anthem approved list for less than I can buy the generic thru insurance which is supposedly an approved drug.

At this point my docs and pharmacist and I talked and tried to research what is going to be the most cost affordable drug to put me on long term. I could not afford what I was being told. Then I called your express scripts and talked to a very helpful lady who seemed to be as baffled as me. I asked her guidance as to what form of this medication would be the most affordable moving forward so my docs can place me on the correct medication. She looked up the 90 day cost of the generic buprenorphine/naloxone tablet which is in your formulary and quoted me almost $4500 for 90 days which made no sense. I can buy the non generic cheaper than you all could provide me the generic tablet. So we were both baffled as to what is going on. She said to Go back To my docs and talk to them. I actually had an appointments with them that same day (yesterday).

After meeting with my doctors yesterday we decided to try another form of the medication. He wrote me a script for the remainder of the one month period for a generic buprenorphine table at 8mg that I take twice a day for a total of 16mg of bupenorphine which is the ceiling and reccomended dose for a patient by the FDA and manufacturer.

So I go to the pharmacy yesterday to pick up my new medication and again the insurance cost is more than I can pay out of pocket myself using a manufacturer coupon. I can purchase the buprenorphine generic tablet for $123 for the remaining 42 tablets which is a 21 day supply. They write the Rx for a month at a time which would be roughly 56-60 tabs and I have about 21 days left in this month period before the evaluate my dose and disease and then move on to the next month etc etc.

So I guess what I am asking you all is what is the most affordable method of medication for me to be on long term.

I was not clear if this high cost issue is a deductible issue or what.

Does Anthem not cover buprenorphine/naloxone?

Why is the cost so high?

This is a medication that was backed by the Obama Administration and the surgeon general to treat long term opiate addiction and it keep many people off of opiates and for some off of Street drugs like heroin. For me I was NOT an IV or heroin user. I was on long term opiates post operative and it's saving my life and has returned my life to a mamangeable normal. It is much better to be on a medication like this as opposed to methadone or other catastrophic opiates.

In the long term this type of medication is a win win for the patient and the insurance carrier as there are much less side effects etc which lowers your risk as it pertains to patient costs etc.

Why is it cheaper for me to purchase the medication without going thru insurance ?

I am very confused.

Is there a process or person at anthem to write too and ask for this medication to be classified differently?

Thanks so much.


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 Post subject: Re: Insurance and costs
PostPosted: Tue Feb 21, 2017 10:09 am 
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Gosh, good luck! I don't have much to offer just because things vary so much from plan to plan.

I don't know what the next health care law will look like, but things are not working now. Being self-employed I get to see the actual cost of insurance with no subsidy, no employer contribution, etc. Ten years ago, even with my 'pre-existing conditions', I paid about $8000 per year with no deductible. Right now I pay about $19,000 per year for my new insurance (for 2 people), with a deductible of $8000 per person. I had to change from United Health because they stopped offering individual plans in WI at the start of 2017. My old plan, last year, cost $14,000 per year, with a $9000 deductible per person. So in just the past one year my cost for insurance increased about 40%.-- which it has done several times over the past 8 years.

A couple days ago I went to the pharmacy to use the new insurance on my 2 prescriptions. I was used to paying $40 per month out of pocket. My new cost was $130. I was confused because my cash cost the month before, when I forgot my new insurance card, was $70. We went through the meds to see what happened-- turns out one of my medications costs $14 for cash, but over $100 if I use insurance!

In other words I'm paying almost $20 K per year so that my out of pocket costs can be higher!

Sorry about all the numbers-- I needed to vent!

Make sure Equi that you differentiate between the different brands-- generic buprenorphine is much cheaper than generic buprenorphine/naloxone. Then there are the 'premiums', zubsolv, bunavail, and suboxone film. When you talk with insurance people they often do not know the relationship between them; they won't know to search for zubsolv, for example, as a replacement for buprenorphine. You will want to ask about each of the options above. Some insurers only cover Zubsolv. Some only cover Suboxone. Some have tiers and give a few options.

The goodrx.com web site will tell you the cash prices in your area-- a great site with a great mobile app.

Good luck- It is really a mess out there these days.


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 Post subject: Re: Insurance and costs
PostPosted: Tue Feb 21, 2017 2:58 pm 
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Thanks so much for the feed back. It makes no sense what happens to us with insurance. It is amazing that I can pay less for my meds without going thru insurance than with it. Go figure. I worry about other addicts who may not have financial means or work and can't afford suboxone and they get discouraged fighting this system and go back to a life of addiction because it's easier to get street drugs. That's where we need the government to help. We have a national epidemic and a very simple solution to a very complex problem. Thanks again. The good news is that in almost 3 weeks it is god send.


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 Post subject: Re: Insurance and costs
PostPosted: Thu Feb 23, 2017 12:02 am 
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I hear you, and I know you were making a point with the comparison to street drugs. But I am always dealing with that situation with patients on methadone. It costs about $15-$20 per day for methadone treatment, which covers the medication and dosing and the counseling. It is completely covered by medicaid, which most people are on when they start. Then they do better, get jobs, and lose medicaid... and private insurance doesn't cover methadone treatment. So they 'save money' by dropping out of treatment, and then return a few months later, deeper into addiction, poorer than before, unemployed, and on medicaid again.

I'm always trying to point out that few people can keep a heroin habit costing under $20 per day-- but that fact is impossible to see from their vantage point.

I guess everything is relative-- and I'll point out that abstinence progams rarely create long-lasting results after their 60-90 days of treatment, that cost $7,000 to $80,000 in Wisconsin. Those numbers make $600 per month, or $6,000 for an entire year, look like a good deal. Then again, I realize that during active addiction, cash is pretty hard to come by, and even harder to save. Which makes it all the more important--- for a person who is out of that rat race to STAY away.


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 Post subject: Re: Insurance and costs
PostPosted: Thu Feb 23, 2017 2:56 am 
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Equi,

I'm not clear on your daily dosage.. If you're taking above 8, I'd think about trying to cut down to that level. It's not that difficult as you're still above the ceiling effect I believe. I started at 32 and dropped down to 16 in a few weeks. Now down to 8 over 3 months. I'm almost sure I could have gone more quickly, but didn't have the cost problem or any other urgent motivation other than my general desire to get down to a lower dose if surgery comes up...

It's a shame you have this problem, but cutting down might be a viable way of bringing your costs in line if you can't find any other solution. Of course no one can generalize from their experience to others, but from what I've read so far and heard on the forum, most people can cut down to about 8 without much difficulty.

I feel very well covered at 8 mg's a day. No cravings at all.


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