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PostPosted: Sat Apr 15, 2017 12:20 am 
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Hi all, have a huge problem right now. I've been taking Suboxone for 4 years now, my Dr tells me I should be on Suboxone as a life long treatment for my chronic pain, been through all the ups and down with regular pain management, been on everything to treat my pain, percosets, vicodin, fentanayl, morphine, just to name a few. None of them worked for long, and I always needed more, hence my Suboxone treatment. Anyway, I'm on disability and my prescription coverage suddenly denied any further coverage for Suboxone, they won't even cover the crappy generic subutex, which cost me $150 for a 30 day supply, if I want to continue taking the regular Suboxone its almost $300 for a 30 day script! I am very limited when it comes to my finances, I just can't afford this! How can my insurance, which is through Medicare/Medicaid (not sure which one) suddenly drop a medication that I desperately need? What are my legal rights? Do I even have any? The only notice I got was a letter sent to my Dr stating that the last script they covered, would be my last. Any help would be appreciated! This is just bullshit! I still don't understand how they can get away with this!
Thanks all
A very pissed off Suboxone client!


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PostPosted: Sat Apr 15, 2017 1:15 am 
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Hey sickofthis,
Welcome here! It will help if we know more. Are you < age 65 and on SSDI? (social security disability insurance) If so, we know that means your health insurance is medicare but who is your pharmacy or prescription drug plan thru? Is it medicaid OR medicare? Who administers it? And what state are you in? And can you redact your details and post an image of the denial letter OR transcribe it for us? It would be unusual to not have medicare or medicaid pay for a bup product, bc its now part of the ACA. Also, the generic is A OK, no worries there, yes its a change for you but its a good med. I'm wondering if the diagnosis or the way the script was written is the issue. There are wonky rules/laws that restrict opioid dependency meds. We just had a poster sure his medicaid plan denied bup yet in reality the plan allowed brand with limits on the quantity but denied generic PLAIN buprenorphine aka subutex. I know seems wonky but true. so yes, please help us help you more! Best tonight, P

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PostPosted: Sat Apr 15, 2017 1:32 am 
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I'm 40, on ssi & SSSI, the insurance company is called envision RX, and I'm in Colorado. They claim that suboxone is not included in their list of covered drugs, or it's included but subject to certain limits. It talks about prior authorisation? I asked my Dr about the exemption claim they talk about, and he says, oh I had my secretary speak to them and she says there's nothing we can do. Which I don't get. Is he just being lazy? Who gives the authorization? Him or the insurance company? I'm going to call them and find out what I have to do. I should have done this a week ago, but I have been extremely sick


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PostPosted: Sat Apr 15, 2017 1:40 am 
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I just read the letter again, and it looks like they are giving my Dr several steps he can take so that I can continue my treatment. It looks to me that my Dr is just too damn lazy to go to their website's!!! He didn't even tell me about this letter until 2 months after they sent it. I don't even know if there is anything I can do! I hope so, but I'm getting really stressed right now!!!!


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PostPosted: Sat Apr 15, 2017 1:43 am 
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Ssdi,stupid spell check!


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PostPosted: Sat Apr 15, 2017 2:28 am 
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Hmmm yes, Suboxone IS listed as covered but generic plain bup aka subutex isn't which isnt surpising but save that wonky why for later.

On the first link below, click the 2nd down on left 'Covergae determination. Search by drug'
https://www.envisionrx.com/PrescribersA ... rescribers

These links are obtained once you've found the above site. Look under parital agonists.
https://www.envisionrx.com/pdf/standard_PDL.pdf
https://www.envisionrx.com/pdf/select_PDL.pdf

Prior Auth form
https://www.envisionrx.com/pdf/Coverage ... 012215.pdf

Not sure why insurance is not working now when you've been on Suboxne for 4 yrs. With this provider? Have they done PA's before?

PAs are a pain but aren't they sorta normal? what do others think?

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Stopping went well -- its the staying stopped -- where the real work begins.
Coming here 'keeps recovery green'.


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PostPosted: Sat Apr 15, 2017 2:40 am 
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I've never even gone through this before, my current provider is the second one I've had, but been seeing him for 3 yrs now. I'm going to call them tomorrow and find out what's what. Thanks for the links. Very helpful!


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PostPosted: Sat Apr 15, 2017 11:11 am 
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PA's are very much a pain, and expensive. At least with the benefit companies I deal with we get approval eventually.
Generally, we get a fax from the pharmacy notifying us that a PA is needed. My nurse completes it and fax's it on to the medication benefit manager or the insurance company. We often get approval at that stage for a few months. If not then I have to draft an appeal letter with more information and the rational for using the medication. That is almost always the last step, but once or twice a year I have to have a clinician to clinician conversation to 'justify' my treatment plan.
Many drugs require prior authorizations and buprenorphine products are one of the 'easier' ones to deal with.
To bad your doctor won't be honest with you, 'nothing I can do', sounds more like, 'too bad, I won't do the paperwork.'

If the Suboxone is being used for pain management it will not be approved in my experience. It has to be for 'maintenance therapy for opiate dependence.'


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PostPosted: Sat Apr 15, 2017 12:02 pm 
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IMO, Suboxone seems to be one of those drugs that most all insurance companies want Prior Authorization. (PA) Lucky for me, the place I go to has one person in charge of just that. It will take her several days to get my meds approved but she always comes through. Like docm2 said, it is usually only for about 5-7 months then we have to go through it again. Two of my medications make my doctors staff and me jump through hoops to get approval. Just be as sweet as you can when you talk to your doctors office so they will do the footwork for you.

The other drug BCBS is giving me a hard time with is Testosterone. My blood levels show I'm low but now they wanted a cardio work up as they seem to think it causes heart disease. My Cardiologist had never seen such a claim before.

So be patient and try to get them to do what other doctors do. Get the PA done.

Good luck and hopefully this won't cause anymore problems for you.

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PostPosted: Sat Apr 15, 2017 3:29 pm 
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It looks like in Colorado, for approved SSDI claimants who then income qualify for SSI, Supplemental Security Income, they automatically are signed up for CO state Medicaid.

CO Medical benefits: For medical care, looks like the Drs need to be signed up as a MediCAID provider. I said MediCARE in prior post above but for those on SSI, it defaults to Medicaid. For those on SSDI who are not income eligible for SSI, their medical is thru Medicare providers.

CO Pharmacy benefits: For pharmacy benefits, looks like you are fortunate bc in CO, those on both Medicare SSDI and Health First Colorado Medicaid, CO defaults to Medicare part D plans provided thru EnvisionRx a subsidiary of RiteAid, a large pharmacy chain. And EnvisionRx lists buprenorphine products as covered but requiring a PA and w quantity limits. What is your dose? Are you over the quantity limits? Scroll down to their page 4 in this link and more bup products are listed than in my prior links. https://www.envisionrxplus.com/pdfs/EIC ... lary_c.pdf

Per Samhsa 2014, some states established Medicaid lifetime treatment limits on buprenorphine products.
1 year limit: District of Columbia, Illinois, Michigan, and Washington
2 year limit: Arkansas, Maine, Mississippi, Montana, Virginia, and Wyoming
3 year limit: Utah
As of 2015 Dr J says Michigan limited to 2 yrs medicaid-and-insurance-coverage-t8094.html

Oh, per a recent AMY post, she found State's medicaid programs usually require counseling in order to get bup. Are you doing?

Happy docm2 and Rule posted, was hoping for you both! Be sure to follow their advice. Your diagnosis must be for opioid dependency. Suboxone needed for maintenance therapy for opiate dependence. CO says will not approve for pain and will not approve generic plain bup aka subutex unless pregnant. And you need to be as nice as can be. Could be your Dr is tired of all the crapolla of billing Medicaid for your Dr visits w the low reimbursement rate and the pain in the ... and $$ cost of PAs. You are lucky to have found a Medicaid Dr! Folks come here often asking for one and few are found. From what we learn from this site, its best to learn all you can and help your Dr/Drs office as much as you can. P

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PostPosted: Mon Apr 17, 2017 1:32 am 
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Try contacting Heritage Hills Family Medicine in Greenwood Village. They take medicaid, insurance, self-pay, etc. I don't know if Dr. Edrich has reached his 100 patient maximum or not.

Here's their number: 303-792-3333

Let me know if you have any problems!

Amy

They do PAs all the time. I should know! He's my doctor!

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PostPosted: Thu Apr 20, 2017 5:21 pm 
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OMG! I'm just dealing with a lazy Dr! I just got off the phone with my insurance company & they said all my Dr has to do is call them or go on their website to start a PA with my diagnosis, after they get the paperwork they will cover me again! That's all my dumbass Dr has to do! But my Dr made it sound like I was screwed and there was nothing he could do about it! Actually this is the fault of his secretary, she is the one that said she called the insurance company, i highly doubt this. Especially when the guy I talked to explained that it's really not a big deal, basically my Dr signs a few papers, sends it off, and bam! Patient back to being covered! I would have never gone through all this crap if my Dr would have just done his job. So sick of idiot DR's! I just got done dealing with my crohns Dr recently. I had to threaten to dump him for another Dr in order for him to put me on the correct medication to control my illness. What is it with DR's in my city! They either have an aversion to treating their patients or are just lazy!


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PostPosted: Thu Apr 20, 2017 9:45 pm 
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Hey sickofthis,
Good work, so you'll go back to your Drs office w the PA info? Ya, easy to see on EnvisonRXs website to do an online PA. Have you been without bup all this time? Or made due w less/day? Any thoughts of a different provider or are they hard to find? might be...Please keep us updated!!

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Did well on Suboxone. Stopped May 2011.
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PostPosted: Thu Apr 20, 2017 9:51 pm 
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Luckily my Dr prescribed me subutex, it's different, don't like it compared to the Suboxone, but it has kept me going at least. Thanks for all the info. Although, I'm going to be on my DR's ass until he gets the PA done!


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PostPosted: Thu Apr 20, 2017 10:03 pm 
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A OK! let us know how it goes. Your plan doesn't cover subutex, aka generic bup bc it says only for pregnant women but at least you have a script for it and can self pay, fill it and afford it for now.
Good going and keep at it! Best, P

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Coming here 'keeps recovery green'.


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PostPosted: Sat Apr 22, 2017 11:51 am 
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Hi sickofthis,

Very glad you got it worked out. Generic will do the trick as most insurance companies are heading in that direction.

Don't be too hard on the doctors office. What little pay he gets for all the paperwork they have to fill out is absurd. It is why there is a doctor shortage coming in the near future. No one wants to be governed by a non-medical office worker who make the decisions the doctor is trained to do.

I never could understand the PA process. When a physician writes you a script, isn't that a prior approval already? It is just harassment of doctors and their patients to save the company money. Just hope and pray enough young people still want to be doctors or we're all in deep Ka Ka. And who wants over hundred grand of loans to pay off when you only make $50,000 (if you're lucky) during residency? Something needs to change the way we treat our dedicated physicians. So many barely make enough to pay the bills. And they have to work over 10 hours a day to do it.

Sorry, just ranting here. My main problem is I read too much!

Good luck going forward!!

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PostPosted: Sat Apr 22, 2017 12:19 pm 
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Rule, totally agree w you and glad you gave this important perspective, especially since bup Dr's that take medicaid are few and far between and sickofthis likely really needs this Dr.

Also, it reminds me that who knows what training the Dr's secretary has and or what s/he tells the Dr. be sweet. be nice. be helpful. go in w the PA filled out. print it off from the link above or envsionrx's website.

On the PA, NY state sued Cigna insurance and won. As a result, across the US, Cigna no longer requires a PA for bup/MAT. During Anthem Insurance's attempted merger w Cigna, Anthem said it too would stop requiring PAs for bup/MAT. I don't know what will happen w Anthem's plan to stop requiring a PA bc in Feb 2017 a US judge blocked the merger. But it still could go thru and PAs may not be required by these 2 giants. Could be good news.

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Did well on Suboxone. Stopped May 2011.
Stopping went well -- its the staying stopped -- where the real work begins.
Coming here 'keeps recovery green'.


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PostPosted: Sat Apr 22, 2017 6:52 pm 
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I get what you guys are saying from the Dr perspective, I'm always nice to my Dr, at least I try to be! For me though, I have trust issues with DR's and nurses. It comes from the last 10 years of dealing with an invisible disease, and DR's and nurses who have looked down on me or outright lied to my face. I try to give every Dr I have the benefit of the doubt. But there are some messed up DR's in the field. As far as an overhaul in the system with DR's, hell, the entire system needs to be redone! Especially with big pharma and their lobbyists making billions off of sick people. How they can get away with charging hundreds of dollars for a life saving drug when it cost pennies to make is beyond me! Most of those people aren't in the healthcare industry to help people, their in it for the money. The ones that do go in to help people are few and far between


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