optumrx and mat tier 3 (brixadi/sublocade) coverage
my s/o has been on-and-off of mat for 6+ years. he was on medicaid for the past few years and transitioned from suboxone to brixadi seamlessly. he had no relapses on brixadi, his mental health stabilized and he was able to work on reparative therapies beyond managing day-to-day cravings.
his employer adopted a kaiser plan that isn’t truly a kaiser plan but is actually western health advantage, which is contracted with optumrx. despite us living literally 5 blocks away from a kaiser pharmacy, and despite his insurance being “kaiser,” he is required to manage his prescriptions using optum’s formulary and membership services only.
his brixadi was no longer covered and he was forced to move backwards to tier 1 generic bupe/naloxone sublingual strips (not even true suboxone) and has been sincerely struggling since, to the point of it affecting his work, his personal life, his physical and mental wellness. his prescriber has been trying to submit a prior authorization but i am seeing now that brixadi actually requires and additional prescription exemption due to brixadi being a specialty drug (in that it has a required refrigeration temperature).
would he have an easier time trying to get a prior authorization for sublocade? they are both the tier 3 (suboxone is tier 1) but sublocade does’t have any additional prescribing indicators like brixadi.
or would it be easier to transition to a tier 2 medication, use that for a trial period and then request a prior authorization for a tier 3? what is the more likely barrier: skipping from a tier 1 to a tier 3, or trying to get both a prior authorization and an exemption with a specialty medication?
he has been at this for months.
i feel so bad for him. his prescriber is ideal option. we are in washington state.