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 Post subject: New Here, NEED HELP!!
PostPosted: Thu Jan 09, 2014 12:23 am 
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My name is Travis and I am 24 years old. I just recently got out of an inpatient 30 day treatment program and was put on Suboxone maintenance since i have tried many times to quit on my own with previous treatment programs but always failed. I am about a month into it and it has worked wonders for my cravings and anxiety etc.! It's definitely made a huge impact on me and my ability to concentrate on other things in my life.. to basically lead a normal life, the life I have always wanted. There is one problem.. I have Blue Cross Blue Shield Anthem. They require pre-authorization for Suboxone, well I received a letter in the mail from them stating that coverage for suboxone has been denied because I never failed a UA for Opiates which makes absolutely NO FUCKING SENSE to me!! I got out of a treatment center and went directly to the doctor, you would think that they hoped I was clean! The good news is that we are in the process of switching over from BCBS Anthem to United Healthcare.. I'm just praying to God that they will cover Suboxone... If anybody can give me any sort of insight or let me know what may or may not happen or what I can possibly do to combat this situation if for some reason UNHC decides to deny me as well it would be much appreciated. God Bless and One Love!

- Travis H.


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PostPosted: Thu Jan 09, 2014 1:09 am 
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thats def weird man..i had blue cross blue shield and it covered it under "brand name preferred" for a 45$ co-pay. i also didnt have to pre-authorize tho....thats def weird that the reason is you never tested POSITIVE for opiates? what does that even mean?...test from who? and when? i would def be questioning that reason for sure

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PostPosted: Thu Jan 09, 2014 2:12 am 
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About the failed UA thing, I don't really know about that... I thought you are covered if the Dr. says you need the med?? Maybe Dr. Junig or someone else will see this and clarify.

But as for pre-authorizations, it's not weird at all and depends on your particular plan. I was on United Healthcare and they also required pre-auths for Sub with my plan. It just means your Dr. has to call a number and authorize it before the pharmacy will fill your prescription. And I think, for me, it was only every 6 months or 12 months..


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PostPosted: Thu Jan 09, 2014 2:46 am 
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pre-authorizations do in fact depend on the plan, but the way it works is that either you or your PHARMACIST have to contact the insurance company and the insurance company then has to give authorization to fill the script on the insurance...they can take up to a week to be authorized and if you dont get it authorized, then you pay out of pocket

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PostPosted: Thu Jan 09, 2014 3:20 am 
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The prescribing Doctor does the prior authorizations, not you, not a pharmacist. Depending on the DR and the company, it can be a 3 minute phone call.

For the next part, you have to be your own advocate or have someone be one for you:

The rest of the situation can likely be taken care of with a telephone call from him/her to your insurance company explaining that you are indeed 304.00 opioid dependent and stand a great risk of relapse without the benefit of buprenorphine at this time as in reality UA's are not fool-proof and really mean zero in the case of someone who has already presented (at least once) to an inpatient treatment program, completed is recently released and has been diagnosed opioid dependent by clinician(s) and referred to a buprenorphine prescriber as part of a comprehensive aftercare plan. There is a specifier within DSM coding (in your case: 304.00 Opioid Dependent; in a controlled environment) for folks who have come from controlled environments such as prison or treatment centers or other therapeutic communities where access to opioids is, on paper, restricted, so people coming from those types of communities don't always meet the other criteria. Best of luck; I hate to hear stuff like this!

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Last edited by TwinCitiesHardcore on Thu Jan 09, 2014 3:48 am, edited 1 time in total.

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PostPosted: Thu Jan 09, 2014 3:32 am 
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Yeah.. I would drop off my prescription and come back to pick it up at which point they would tell me my Dr. will need to call so and so hotline and give a prior authorization. They would usually have also called my Dr. but he might not get the message right away and I would call him myself. It was a pain sometimes and trust me, it's the Dr. who needs to authorize prescriptions not a random pharmacist.


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PostPosted: Thu Jan 09, 2014 1:21 pm 
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prior authorizations by a doctor (for example, to obtain a re-fill in certain instances), and PRE-AUTHORIZATIONS required by an insurance company are 2 different things, check it out peeps!

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