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PostPosted: Mon Feb 11, 2013 1:10 am 
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Just a short request tonight. I need help gaining an understanding of how buprenorphine/Suboxone is covered, across geography, insurance carriers, and state Medicaid agencies.

Please write to me and share what you know. Does your state limit coverage for buprenorphine to a specific length of time? Have you appealed that limit? Did you win or lose? Does you insurer limit or deny coverage?

I am interested in responses with 'just the facts', or more lengthy descriptions of interesting or unique experiences. I will assume that anyone who writes wishes to remain anonymous; if you are willing to speak with an investigative reporter about your experience getting coverage, please specifically write that I can share your name/contact info.

Please send comments to drj (at) suboxonetalkzone.com , or if you prefer you can share them below.

Thanks!


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PostPosted: Mon Oct 21, 2013 6:58 pm 
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Location: Rude/Nasty Chicago
I have had no trouble having medicare cover my suboxone; nor my blue cross/shield gap policy. I live in Illinois - began on 24mgs per day and now down to 3. Due to the cost, I was in the 'donut hole' in April and in the 'catastrophic' level of prescription coverage for Blue Cross/shield in September.

Occasionally when I was really short of money, my pharmacist would use a mfr coupon for $50 off, but got 'busted' because I was on government aid (medicare) and the coupons weren't meant for that.

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PostPosted: Fri Dec 20, 2013 6:12 pm 
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Don't know if you are still wanting replies to this but...here ya go Doc.
I live in North Carolina and when I began treatment I had Blue Cross Blue Shield but when I lost my job 3 months later I went on Medicaid.
BCBS requested prior authorization and then denied it ( but they never had any problem paying for my opiates while I doctor shopped and went to the er 3 times a month). By the time I received their denial letter I had just been let go and was no longer eligible to keep their coverage.
Medicaid also requested prior authorization but approved it in 24 hours and approved it for 1 year.


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PostPosted: Tue Jul 22, 2014 6:48 pm 
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I live in NJ
I am on medicaid, and have horizon nj health
They cover suboxone but limitations apply
They do not specify what kind of limitations but im assuming the duration of the therapy. They require prior authorization every 6 months. I been on it a year so far. This past prior authorization, they wanted alot more info before deciding like last 3 drug screens and alot more clinical information.

My doctor visits are covered as well bit i travel 63 miles ( 1 hr 20 minutes) to get there, and the same on the way back. And i am required to go every 2 weeks.

I found this is the only doctor in the entire south jersey region that accepts medicaid. Horizon nj health helped me find this doctor after lots of searching. Every other doc charged $360 at least for an initial and $100 for follow ups. I was lucky enough that the representative at horizon was on suboxone herself, and willing to help. Every other rep was rather unhelpful.

I too am seriously interested in how ling they will cover this for, i am afraid to push it to 2 years. I take generics even because of this fear.


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PostPosted: Thu Sep 04, 2014 9:01 pm 
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So, I started out on Suboxone back in 2009 through Medicaid. They covered a year of treatment and then an extra year if you had someone from the state advocate for you, which is what I did. So I was on it legally from 2009 to 2011 after which they would no longer cover the medication or the out patient treatment. I began receiving my 4mg a day dose from a relative who was prescribed more than she needed and her insurance, which I believe is Medicare and Blue Cross/Blue Shield, covers about eighty percent of her Suboxone without any caps. Her doctor agrees she needs to be on her entire life. Anyway, about six months ago in April of 2014 I went in search of my own Suboxone doctor after having been working for awhile so I could afford it. I got back on Medicaid and United Healthcare and they've been covering 100% my prescription and the doctor's visit. They won't cover group or private therapy sessions but they require you attend them as often as you can and submit a UA once a month in order to continue their coverage, which caps out after a year. They will extend your coverage if you relapse after a few months or so and need to start treatment fresh and then you'll get another year to recover. So, those have been my experiences with Washington State Medicaid/Apple Health/United Healthcare insurance services. Hope this helped some.

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PostPosted: Sat Jan 17, 2015 7:20 pm 
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I'm new to sub and this board. I am just reading this and never thought about what if my insurance won't cover for a long time. I have decided I need long term sub treatment (as in years). I have caresource insurance now (Medicaid) because I don't make enough at my job so I qualify. Will they cover it long term? I was just assuming they would. I hope so because I can't afford it out of pocket and also I know I will need it for life. Ugh!
Maya


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PostPosted: Mon Jan 19, 2015 5:26 pm 
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It depends on the state-- Michigan limits to 2 years, but some states cover indefinitely. The frustrating thing is that the standard of care is now to keep people on the medication indefinitely-- yet the idiots at some medicaid agencies ask questions in the approval paperwork such as 'what are your plans to taper this patient?' I wonder-- do they require people with heart disease or diabetes taper off their meds too? I wonder if they are being 'guided' by bozo doctors, or just making up the rules on their own?


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PostPosted: Thu Jan 22, 2015 11:32 am 
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I talked to my sub doctor about how long I will have coverage. She said some insurances (I have Medicaid) only cover for a year, but in those instances she writes a letter stating why the patient needs it longer, and will do this every year until you want to taper, or forever if you want to be on it that long. Do you think Medicaid will listen to her when she says that I need to be on it forever? I can't afford the medication monthly if insurance doesn't cover it. I don't make enough at my job as it is so I qualify for Medicaid. Any hope for me continuing long term if my doctor pleads my case to them?? Help please! I can't imagine going off in just one year! That would kill me!
Maya


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PostPosted: Sat Jan 24, 2015 4:50 pm 
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Hopefully your doctor will be willing to work with you if you aren't covered for more than a year. What is positive is that you have a doctor willing to advocate for you. I think there's a really good possibility that you will be covered for longer than a year. I also think that there is a good chance that your doctor would prescribe a lower cost bupe medication if your meds are no longer covered.

Amy

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PostPosted: Sun Jul 26, 2015 3:57 pm 
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I'm in Mississippi, name probably gave it away, and our state Medicaid is two choices Magnolia Health or United. I was told that Magnolia was better for prescriptions and well just superior to United. What Magnolia told me when I signed up with them was that I would be covered for scripts as long as my Dr. wanted me on them. So my doc eventually gets me to 2 1/2 strips a day after about 3-4 months of adjusting the dose. The first 8 months went by great. I was active again, and all the things that come along with using the drug as iit's intended to be used. Passed all my drug tests. Life was great.
Early Dec of 2014 I go to the Doc and get a script and when I get to the pharmacy they tell me that my year is up. I had to borrow money to get enough strips to be able to ween myself off. Magnolia claims they told me all this up front, but I would've had a year plan if that was the case.
So here in MS what I've heard people are doing is jumping from one provider to the other year by year to be able to stay in the program until the doc weens them off.
To let you know how our leaders feel about treating drug addiction here I'll finish with this. The mayor of Tupelo wouldnt allow a Methadone clinic because it would "attract drug abusers."


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PostPosted: Thu Jul 14, 2016 4:32 pm 
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My husband was on subs for 7 years through NJ MEDICAID and they never cut him off. Idk if it plays role in their children ecision to do so, but not once did he have a dirty urine. I've heard of ppl that test positive for illegal drugs getting kicked off by their insurance. Not sure about caps but his won't authorize above 24mgs per day without prior authorization but thats fine bc he only takes 6 mgs daily.


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PostPosted: Thu Jan 26, 2017 3:28 am 
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I live in Massachusetts and Masshealth will cover it indefinitely, I believe. (I've been on this little orange miracle for 5 years now and no static or issues with any limits, just an initial prior authorization hang-up that wasn't a pleasant 2 days). However, they do, in some cases, require patients to fill with the films from RB. I was switched from Masshealth Care Plus to Masshealth Standard this past week during the annual open enrollment, and because of my whopping $1/hr salary increase I received in Nov., was subsequently switched from tablets to the films. When I went to fill my script the pharmacist had to ascertain a new script because the script didnt specify films and Masshealth Standard only pays for films. I feel pharmacolgically demoted...lol.


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PostPosted: Thu Jan 26, 2017 4:04 am 
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I like that! Pharmacologically Demoted. That would be a good band name, I think.

Amy

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PostPosted: Thu Jan 26, 2017 8:56 pm 
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I'm in michigan, my first policy with blue Cross had a 600 dollar cap out for fiscal year, and we know how fast suboxone can eat up 600 dollars. My next policy with blue care network covered brand film only, no generic, had to pay Co pay til deductible was met, which meant I only had 2 months out of the year that it was fully covered

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PostPosted: Tue Mar 14, 2017 9:49 pm 
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Jenilee182 I am wondering if you could let me know the name of the sub doc you see? I live in south jersey and have horizon and having a hard time finding help.


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PostPosted: Wed Mar 15, 2017 1:44 pm 
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I live in Texas, I have United Health care/ They cover Zubsolv only and not Sub strips. But with the Coupon its $10 .

They have to get a prior Auth every 6months but it is always approved . So I think it is indefinitely covered.


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PostPosted: Wed Mar 15, 2017 2:55 pm 
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Raudy, are the member I remember as having treatment resistant depression?

Amy

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PostPosted: Thu Mar 16, 2017 6:36 am 
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Location: Southeastern US (Alabama)
In Alabama ;

I've been in every imaginable situation....

Started with no insurance, cash only, dr was in a methadone clinic...$300 first visit covered 2 weeks + 2 weeks of drug test..only got 14 pills (the N8 RB hex shaped...long before films)..

From there, insurance covered med only, dr in an office setting, still cash only, $110/month..monthly visits w/no refills...
Copay on med (still the N8 pills, long before films-- 2009 ish) was around $50 for 90 pills/monthly.

Onto massive economic hardship (shortly prior to 2010..December 2009 or so) job loss/insurance loss..
continued dr visits, but forced to buy medication in 3-4 pill increments. Was costing around $15 to $30/day when the money could be borrowed or earned.

Forward to great job in late 2010 with great benefits. Still not covered on office visits with any doctor...but medication is covered 80%.
I've even been on the patient assist program, where RB mailed my pills to my Dr...but you can only be on that for 11 months at a time.

Right now, I'm paying $150 every 3 months to my doctor (even with Southern Company insurance, still no coverage for office visits)
Insurance plan we choose each year in open enrollment is pretty decent. I have an $80 cap on name brand/non generic.
So, when my medicine runs $674 ..I'm left with the $80 copay...minus the RB/Indivior coupon which pays another $55 towards my $80...out of pocket cost is $25.

$50/mo dr + $25/mo med...so $75/monthly if you break it down to that...

Way less than the $500 to $1500/month habit I had back in 2004 thru 2008

No prior authorizations to deal with ...I have in the past, but not with Southern Company insurance.
No caps or limits. Been on Suboxone since my wife started her job with them in December of 2010, they've paid every month without any problems.
And it aint cheap on their end..

I can log into my Caremark and see the company cost/my cost....per month they are paying $674. I'm paying $80-$55 coupon...

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