Does Aetna require prior authorization for a Suboxone (buprenorphine/naloxone) prescription?
In 2017, Aetna announced that it would stop requiring prior authorization for buprenorphine/naloxone (common brand names include Suboxone and Zubsolv) when prescribed for opioid use disorder. This announcement was met with great relief by Aetna members with opioid use disorder and by the providers who treat them.
As you may know from past experience having prescriptions filled, prior authorization is a process by which the prescribing clinician has to submit paperwork to the health plan or insurance company requesting approval for the medication before the pharmacy can fill it. This can add several days to the wait to pick up a prescription. With many medications, this wait is a mere (but major) frustration, while with others it is physically hazardous. With buprenorphine/naloxone, a delay in receiving meds can lead to intense withdrawal symptoms and a higher risk of resumption of opioid use.
Does that mean that Aetna will definitely not require prior authorization for buprenorphine?
According to Aetna’s website, they don’t require prior authorization for members insured through an employer-based plan to get buprenorphine/naloxone. So if you have insurance through your job or your parent’s or spouse’s job, your clinician won’t have to request prior authorization.
However, if you have a plan through Aetna Medicare or Aetna Medicaid you may still need prior authorization.
For all Aetna plans, there may be a limit on the quantity you can be prescribed. For example, on a search we ran, the quantity Aetna would cover for generic buprenorphine/naloxone tablets (8mg/2mg) was limited to three tablets per day, without requiring prior authorization. There also may be restrictions on which brands of buprenorphine/naloxone you can get without prior authorization. Your plan may not cover Suboxone, but may cover Zubsolv or generics.
Is precertification the same as prior authorization?
Yes. Precertification, preauthorization, and prior approval all mean the same thing as prior authorization. These terms are used interchangeably.
How can I find out for certain if my Aetna plan covers my Suboxone (buprenorphine/naloxone)?
Health plans have lists of medications they include in their prescription drug benefits. These lists are called their formulary or drug list. You can check the formulary for your specific Aetna plan on the Aetna website. Choose your plan from the dropdown menu and then click “View Pharmacy Plan.” You can either view a PDF of the formulary or click through to a searchable list on which you can find the covered drug. Be sure to familiarize yourself with the codes and icons they use, so you can be prepared for any restrictions on your prescription drug coverage.
What if my Aetna plan DOES require prior authorization for the quantity or brand of buprenorphine I need?
Sometimes an individual needs medication in a quantity that exceeds those approved by Aetna without prior authorization. Or maybe they have a bad reaction to a particular brand of buprenorphine/naloxone but do well with a brand that is not covered. If this is the case for you, or if you have an Aetna Medicaid or Aetna Medicare plan, your clinician will need to submit a request for prior authorization. If this happens:
- make sure not to miss your provider appointments. If there is already a possible delay due to the need to prior authorization or precertification, you don’t want to add on any more wait time!
- follow up with the pharmacy if you don’t hear from them by the date/time expected. You can also reach out to your provider. At Workit Health, you can connect with your care team via the in-app chat feature.
- call the number on your insurance card if the need is urgent. If you talk to Aetna directly, you may be able to submit an urgent request for a faster decision. Note that this is not guaranteed!
Will any pharmacy fill my Suboxone (buprenorphine/naloxone) prescription if I have Aetna?
No, you will want to check with the pharmacy to be sure that they accept your Aetna plan and also have the medication you need. Pharmacies sometimes run out of certain medications. Some pharmacies are also very cautious about dispensing buprenorphine because they fear it will be diverted. So they may have additional red tape for you to navigate, despite the fact that Aetna covers the medication.
Does Workit Health accept my Aetna plan for opioid use disorder treatment?
Workit Health accepts Aetna for our clinical programs for both opioid and alcohol use disorders in many states. Click here to use our insurance checker to find out if your plan is accepted, or call the number on the back of your insurance card.