Does Horizon Require Prior Authorization for Suboxone?

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Does Horizon BCBS require prior authorization for a Suboxone (buprenorphine/naloxone) treatment in New Jersey?

If you’ve ever had to wait for prior authorization to get treatment or to fill a prescription, you know that it’s a pain at the best of times. And when you’re struggling with cravings or withdrawal symptoms it’s never the best of times.

Prior authorization is a process by which the prescribing clinician must submit a request for approval to the health plan or insurance company before they can provide treatment or before a medication prescription can be filled by the pharmacy. This can add several days to the wait to get the care you need. For some medications or treatments, the wait is just annoying, but for others, it can have a major impact on your wellness. With buprenorphine/naloxone, a delay in receiving meds can lead to a higher risk of resumption of opioid use, which is life-threatening.

Fortunately, Horizon Blue Cross Blue Shield of New Jersey recognizes the vital importance of treating opioid use disorder and does not require prior authorization to receive treatment in most circumstances.

Is precertification the same as prior authorization?

Yes. Precertification, preauthorization, and prior approval are terms that are used interchangeably. They all mean the same thing as prior authorization. 

Does Horizon BCBS NJ require prior authorization for me to see a provider who will treat opioid use disorder?

In most cases, as long as you are receiving outpatient treatment from a provider who accepts Horizon Blue Cross Blue Shield of New Jersey, you will not need prior authorization to see a doctor who treats opioid use disorder. This applies to telemedicine programs like Workit Health as well as to more traditional office-based care and outpatient treatment programs. However, Horizon DOES require prior authorization for inpatient (residential) treatment—what many people call rehab—with many plans.

How about my medication? Will Horizon BCBS NJ require prior authorization for a buprenorphine prescription?

According to the Horizon BCBS NJ website, they don’t require prior authorization for generic buprenorphine/naloxone to treat opioid use disorder, although there may be a limit on the quantity you can be prescribed. For example, on a search we ran, the quantity Horizon would cover for buprenorphine/naloxone (8mg/2mg) was limited to a maximum of four doses per day, and buprenorphine/naloxone (12mg/3mg) was limited to two doses per day.

There also may be restrictions on which brands of buprenorphine/naloxone you can get without prior authorization. Your plan may not cover Suboxone (the formularies I looked at for this post didn’t cover the brand name version), but should cover generics and may cover other brands.

How can I find out for sure if my Horizon BCBS NJ 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 Horizon plan on the HorizonBlue.com website. Click through to the formulary that applies to your plan to view a PDF of the drug list. Then you can search using the Find function (CTRL + F or ⌘ + F). Be sure to familiarize yourself with the codes and icons Horizon uses on the chart, so you can be prepared for any restrictions on your prescription drug coverage. You can also call the number on the back of your insurance card to ask for clarification. Note that on our search, generic options were preferred and had the most coverage.

What if my Horizon BCBS NJ plan DOES require prior authorization for the quantity or brand of buprenorphine I need?

Sometimes a person might need medication in a quantity that exceeds those approved by Horizon BCBS NJ without prior authorization. Or maybe they have a poor reaction to one particular brand of buprenorphine/naloxone but do well with a different, less preferred brand. If this is the case for you, your clinician will need to submit a request for prior authorization. If this happens:

  • make sure not to miss appointments with your provider. If you’re already facing 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 Horizon 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 Horizon BCBS NJ?

No, you will want to check with the pharmacy to be sure that they accept your Horizon plan and also have the medication you need. Pharmacies have been known to run out of certain medications, and some pharmacies have been reluctant to dispense buprenorphine out of fear that it will be diverted. So your pharmacy may have additional red tape for you to navigate, despite the fact that Horizon covers the medication. You will also want to check on what your prescription co-pay is ahead of time, so you’re not taken by surprise at the register.

Does Workit Health accept my Horizon BCBS NJ plan for opioid use disorder treatment?

Workit Health does accept Horizon BCBS NJ 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.

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Alaine Sepulveda is a content strategist in recovery from alcohol. She believes that engaging people and sharing stories with them allows us to spread knowledge, and to help others in the path to recovery. She holds an MA in Communication Studies from New Mexico State University.

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