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PostPosted: Sun Jan 04, 2015 1:36 am 
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Does anyone use Anthem insurance to cover their suboxone?

My old insurance covered everything for two years. Now I have to get new insurance from Anthem that started in January 2015. The new insurance will likely require a pre-authorization. One of the qualifications for the PA is this:

Quote:
Individual must participate in a comprehensive rehabilitation program that include
psychosocial support (documentation of the treatment plan and taper strategy not
required, but verification upon request must be provided)


I went through outpatient therapy and treatment in 2010 when I initially got on the medication. Since then, I only go to the doctor every 3 months for a check-up. It's not necessarily rehab, it's more of a medication check to see how I'm doing.

Is this enough to satisfy the qualification? Am I over-reacting? I really need this to be covered, so anyone else with Anthem insurance & info, please share. Much appreciated.


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PostPosted: Sun Jan 04, 2015 10:11 am 
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I work with insurance's so two questions i have are

1) Is Anthem your medical and pharmacy coverage or do you have caremark or a different RX insurer? For example, i have BC with caremark as my pharmacy coverage..

2) What is before the quote you show? You can PM me if you want.With my insurance they would only cover generic last year so i had to try that first (i hated the pill form). My doctor called & told them i had no success & they gave me the film's again. All i had to do was take the pill for 3 days.

The good news is that they say they don't need documentation of treatment unless requested. That means you can be attending AA or NA or any other "recovery" based meetings and if they request info your doctor can relate you told him/her that you go to meetings and you are doing what you should for your personal recovery. ie clean urine or always coming to your appointment.

Insurance company's never want to pay for anything anymore & the more expensive the medication or treatment the worse.

You can also call your pharmacy & ask them to see what will be covered so you know before your appointment.

Hope this helps..


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PostPosted: Sun Jan 04, 2015 3:07 pm 
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Thanks for the response. I'm hoping it's more of a formality and that my Dr visits and past participation in therapy will count. Here's the entire criteria:

Initial requests for all dosage forms of Suboxone (buprenorphine with naloxone) may be
approved for individuals who meet the following criteria:

I. Individual is being treated for opioid dependence; AND
II. Individual is 16 years of age or older; AND
III. Prescribers personal DEA and unique Drug Addiction Treatment (DATA) 2000 waiver
identification number (that is, X DEA number) provided; AND
IV. Individual must participate in a comprehensive rehabilitation program that includes
psychosocial support (documentation of treatment plan and taper strategy not required,
but verification upon request must be provided)

Maintenance therapy requests for all dosage forms of Suboxone (buprenorphine with naloxone)
may be approved for individuals who meet the following criteria:

I. Individual is being treated for opioid dependence; AND
II. Individual is 16 years of age or older; AND
III. Prescribers personal DEA and unique DATA 2000 waiver identification number (that is, X
DEA number) provided; AND
IV. Individual must participate in a comprehensive rehabilitation program that include
psychosocial support (documentation of the treatment plan and taper strategy not
required, but verification upon request must be provided); AND
V. Individual has a negative urine drug screen for opioids to continue treatment
(documentation of negative result not required, but verification upon request must be
provided); AND


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PostPosted: Sun Jan 04, 2015 4:24 pm 
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Sounds like Tiki might have more info for you as far as the technical insurance info you need, but I wanted to weigh in with my own experience.

I had Anthem BCBS of TN with Caremark as my prescription coverage for several years. When I began suboxone treatment I was required to get a PA from my doctor, which did take about a week to process. My doctor took care of all of that for me before my first appointment. During treatment I received 8mg per day, so 30 strips per month. I used the prescription discount card provided by RB and my meds were always covered 100%. No co-pay. I was never required to do any outside group or individual therapy. I'm not sure if this is still the case (it was from 2012-2013 when I used it), and it can vary from state to state or from plan to plan. A family member of mine had Anthem BCBS of Alabama and was required to pay for their meds up front and was reimbursed at the end of each month. But they also were not required to do any outside meetings.

Hope this helps!

Q

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No one can make you feel inferior without your consent. ~ Eleanor Roosevelt


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PostPosted: Sun Jan 04, 2015 5:00 pm 
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Hi, I'm Queenie,

I have Anthem and I have been on Suboxone for 4 years. I have never been asked to provide the info you speak of and my pharmacist has not spoken to me about any. I saw my doctor last month and he didn't mention anything either. I see him every 6 months.

I hope goes smoothly. We don't need anymore aggravation as it is.

Love, Queenie


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PostPosted: Sun Jan 04, 2015 10:43 pm 
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Insurance companies are getting more involved. A couple here in Minnesota require a new prior authorization if there is any change, including dosage changes such as going from 12 mg a day to 8 mg a day. They are requiring drug screens to be done every month. They act like they are doing us a big favor by granting a variance when someone has been clean for three years and not coming in the office every month.
Also, they will only provide 30 days at a time, no more, no less, completely negating the close monitoring we are supposed to do the first 6 weeks. Makes me nervous when a person walks out of the pharmacy, new to this medication and have 30 or more strips. Have to hope they will return each week with their strips for a count and a check in.
In the past 6 months I have come to I loath the insurance companies much more than the DEA or State Board.
[quote]I hope goes smoothly. We don't need anymore aggravation as it is.[/quote] It is getting worse, not better.


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PostPosted: Mon Jan 05, 2015 8:47 am 
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After reading & responding to this question i checked my own coverage. Don't ya know it's changed again and the maximum they will now cover is 60 generic pills a month and films are not covered. That is the new recommendation, no more than 16 mg a day.

You can believe i will be on the phone with my doctor and pharmacist today! My doctor is a good guy so i know he will fight the insurance company but i will also have the pharmacist follow up so there are no surprises like last year.

I still think if you fib and tell your doctor you go to AA/NA it will cover you. I bet the insurance won't cover the rehab they want you to do :roll:

When an insurance company can over-ride a doctor that's BAD medicine in my book.


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