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ADD medication denial

So you can’t get your ADHD medication approved by insurance? Part 1

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My patients have been complaining for years about getting there prescribed ADHD medications approved by their insurance companies. With each passing year this becomes increasingly more difficult. Since January 1, 2018, with insurance companies making changes to policies and formularies (tier system that determines copayment amounts for medication), patients have found the medications they have been on for months to years are now being denied. Insurance companies, citing “step therapy”, are requesting patients try medications on tier 1 before they get approval for higher tier ADHD medication.

So how has this evolved? Years ago the focus on cost was not as acute as it has become in the last two years. As a result, designated medications on Tiers have changed with consideration to cost containment by the insurance companies and their designated pharmacy benefit managers (CVS Caremark, UnitedHealthcare, etc.). It used to be that prior authorization for medications was a routine administrative procedure. For cost containment, prior authorizations are now often denied on the basis of doses exceeding FDA approved daily maximum, change in the tier status of a medication, or number of pills contractually covered per month.

Such denials can then be addressed in an appeal process. However, if the initial denial is based on the request for “step therapy” and you are a patient in Maryland, it is important to know that Maryland made step therapy illegal in 2014. So, you send back the initial denial with a letter stating Maryland law on step therapy.  You can also find this information on my previous blog. As far I know, Maryland is the only state with this law and I, for one, have used it effectively to get step therapy denials overturned.

Routinely, the appeal process involves sending additional medical documentation. What do they want to see? Have you been on lower tiered medications, doses, duration, effect and side-effects? Composing this information and letter is very time consuming for your prescriber and will frustrate both of you when the appeal denied. I simply send copies of my medications sheets and let them cull through it for the information they request.

You and your prescriber can escalate the process and request a peer-to-peer review. By phone, the treating physician reviews the medical history with an insurance designated physician, who may or may not be a psychiatrist. After I provide the necessary medical information and historical course of treatment to the reviewing physician, he/she asks additional questions necessary to fill out their form they submit to the insurance company. What is surprising is that the reviewing physician has no authority to make a determination as to the legitimacy of the requested medication or daily dose. The reviewing physician simplies gathers information to submit to the insurance company. More often than not this turned into a pro-forma administrative time-consuming obstacle as the outcome was often a second denial. Here too insurance company misleads us into believing the physician-physician review results in a medical agreement about treatment but no such thing happens since the reviewing physician has no authority to authorize medication- as one physician told me “This is my contracted role in this process.”

An example of the response to such an appeal comes from CVS Caremark on a recent denial for my patient’s high dose Adderall XR: “A doctor has reviewed all the documentation it was submitted and is determined that your request for medication was not medically necessary or experimental and investigational.” But as you see, the doctor who reviewed the medical information with me had no authority to authorize medication, so how could he/she authorize the denial?  This patient had been on high dose Vyvanse then high dose Adderall XR over the past three years. His control of ADHD symptoms was much better, duration of control was approximately 12 hours, and he did not have any significant side effects or changes in blood pressure and pulse. In my opinion, there was no medical justification for the denial and interuption of his effective daily dose of Adderall XR for the past 1 year, which, by the way, had been approved up to this new year.

What did we learn today?

  1. Obtaining your ADHD medication may grow more difficult.
  2. Anticipate that medication previously approved may be denied as insurance formulary tier designations change.
  3. Plan alternative medications with your prescriber if necessary.
  4. Do not accept the insurance companies’ explanation as to the legitimacy of their denial.
  5. Coordinate with your prescriber to see if they have some insight. They have to do this with dozens or hundreds of patients.

What’s coming in next blog on this topic? I’ll enumerate additional insurance objections and misleading information, and how to effective challenge their position to get the medication you need. Forewarned is better armed.

Sincerely hope this sheds some light in the dark corners of ADHD treatment access.

David W. Goodman, M.D., FAPA

 

 

Insurance companies restrict psychiatric medications for patients Part 1

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With each passing year, insurance companies are instituting contractual clauses in benefit packages that restrict psychiatric medications for patients. Specifically, this comes in the form of prior authorization for stimulant medications, despite FDA approval of these medications for ADHD. Combine the prior authorization process with changes in drug formularies (a tiered list of  medications that an insurance company will authorize) and you end up with a series of hoops to jump through. For doctors, this is an increasing administrative burden on staff to get authorizations for patients who desperately need their medication. With each insurance company having their own process, it becomes impossible for doctors’ offices to keep track of how to process this information. The unnecessary delays can leave patients without medication and treatment.

On the occasion that a patient requires medication dosing outside the PDR’s dosing guidelines, the pro forma initial authorization denial leads to submitting paperwork for an appeals process. Were the appeals process above board and transparent, I’d have no problem but the conflict of interests abound and patients are denied medication and dosing that had previous worked well.

In the appeals process, the patient’s case is assigned to an “independent” medical reviewer. This may be a physician or, in some cases, a pharmacist. The physician reviewing the appealed case is, in my experience, not an expert in the disorder or medication dosing being reviewed and therefore has very limited insight from which to review the specifics of unusual dosing for, say, a rapid metabolizer. In addition, they are often unfamiliar with relevant research supporting the unusual but appropriate dosing, instead relying on FDA recommended dosing.

The reviewer’s reliance on FDA recommended dosing may serve several purposes:

1. FDA dosing gives their opinion legitimacy;

2. If the insurance goal is containment of expense, an appeal denial by the reviewer serves the insurance company goal;

3. If the review’s income is dependent on triaged work from the insurance company, the reviewer has a conflict of interest. If he finds in favor of the patient’s treatment, the insurance may stop assigning work to them;

4. If a reviewer’s recommendation favors of the patient’s medication and dosing, the insurance company is not obligated to follow the recommendation and can triage the review to someone more favorably disposed to the company’s goal. It is important to know that the reviewer’s recommendations are confidential and will not be conveyed to the treating physician who discusses the case with the reviewer. Transparency and good faith seem not to be part of this process.

5. While the insurance company sites its concern for patient safety in their letters to patients, the doctor-patient relationship is compromised if the patient comes to believe from the insurance company that the doctor is “over medicating” the patient;

6. The reviewer can request double blind placebo controlled trials of higher medication dosing knowing that such research doesn’t exist because pharmaceutical companies don’t typically investigate the research question “if the patient doesn’t respond optimally to a dose, would they respond to higher doses?” And so without the controlled trial to report to the insurance company, they can easily deny the dosing, despite the fact that the patient had been on the higher dose for 2 years with benefit.

This circumstance typically occurs when you change a policy or carrier and this dosing is denied. Although insurance companies often cite their concern for the patient’s safety if dosing is higher than noted in the PDR, this doesn’t make medical sense if the patient responses well, blood pressure/pulse are normal, and there are no problematic side-effects. Therefore, under the guise of concern for the patient (as if the doctor is being cavalier in dosing), they make medication decision for economic motives. While I understand the need to contain the expense of medications for their budget, patients suffered needlessly and their productivity is reduced, sometimes leading to job loss and/or divorce.

In my next blog, I will give a specific example of how this process has compromised my patient’s treatment leaving them with impairments from persistent ADHD symptoms. In the next blog I will refer to a specific company and reviewing physician who, in my opinion, demonstrate the reality of the above 6 issues I highlight. I will also give you very specific actions that patients can take as advocates with their doctors to secure their effective treatment.

David W. Goodman, M.D.

 

Arbitrary medication denials leads to restriction of optimal treatment

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In my periodic entries of insurance companies’ denial of ADHD medication dosing, I offer you this recent example.

A female in her late 20s treated for ADHD with a combination of Adderall XR and Strattera. Strattera adds a benefit for her executive function not optimized with Adderall XR. I carefully dosed the Strattera upward and suggested increase to 120 mg daily.

Well, the folks at BlueCross Northeastern Pennsylvania denied the dose “As per the FDA recommended dosing guidelines for Strattera in adults the maximum dose is 100 mg per day.” Correctly stated per the package insert for Strattera. “There are no data that support increased effectiveness at higher doses. Therefore medical necessity for 120 mg of Strattera per day has not been met.”

This last statement is a misrepresentation of the purpose of a drug package insert. In fact, the adult registration trial for Strattera submitted to the FDA lists the dose that was used as up to 120 mg daily. Registration trials are designed for the purpose of seeking drug approval for a specific disease state. This research DOES NOT answer the question “If the patient is suboptimally treated with x dose, will they improve further with a higher dose?” So the logic of their denial is a misrepresentation of research for the sole purpose of constricting treatment and conserving money, in my opinion.

Yet more damage is done with these letters. People reading these letters may think the doctor is over-dosing them and not considering safety issues. This is simply not true since safety data on medications are routinely undertaken at much higher doses. There was no unusual safety concern with Strattera at 120 mg daily in the adult registration trial.

It is unfortunate that I find myself blogging about the denial of medication authorizations for my patients who clearly need better outcomes from their medications. While these companies have set up appeal processes, this tends to administratively time consuming without any guarantee that the medical necessity and logic of the dose request will be reviewed with the patient’s interest in mind.

So, what can YOU do if this happens to you? Here are the steps:

1. Call the insurance company and respectfully explain why you need your medicine. If the person is unresponsive, ask to speak to supervisor. If you don’t get to speak to someone with authority, ask if the conversation is being recorded and tell them to “tag” the audio file so that the State Insurance Comissioner’s Office with be able to listen to the audio file. Now, write down the date and time.

2. File a complaint with your state insurance commissioner’s office. You can find the contact information online by searching “<your state> insurance commissioner office”. In your complaint, which should only be one page (no reads anymore), state your brief history of medication history and why it is necessary to have the new dosing authorized for coverage. Write that you spoke with the insurance on what date and time.

In my experience, more often than not, you’ll be getting your approval. However, no guarantees. Good luck.

 

CVS/Caremark deny prescription for bogus reason

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With each passing day, I encounter an increasing number of obstructions by insurance companies to authorize and provide my patients with their much needed medication. In my last blog, I highlighted Sav-Rx bogus reason to deny my patient the authorization to continue effective medication because of a change in policy coverage despite being on this dose for over 6 months .

Today, I’ll highlight CVS/Caremark’s explanation for “canceled” prescription to a patient who was on Vyvanse 70 mg in AM but needed to reduce the dose to 60 mg in the morning because of difficulty falling asleep. Here is the quote for canceling the 60 mg prescription sent to them.

“We were unable to fill this prescription because taking it is not advised based on your allergies, health conditions or potential interaction with another drug you are taking. Please contact your prescriber for assistance.”

While you might think there is legitimacy in this reason under the guise of safety, the fact is that the patient has been on Vyvanse since 2008 and there has been no clinical relevant change in his treatment that merits CVS/Caremark’s reason.

Such denials under the seeming auspicious of patient safety seem to be nothing more than denial of coverage for cost containment, in my opinion.

I encourage patients to call insurance companies and complain. When that doesn’t work, file a one page complaint with the State of Maryland Insurance Commissioner’s office. This office needs to be aware of the denial of treatment by insurance companies with regard to medication treatments for ADHD.

I intend to post more examples of such denials by specific companies along with the quoted explanation of denial. Perhaps someone with influence over this issue will find these examples ample evidence to formally question the insurance coverage of this and other medical treatments.

October is National ADHD Awareness Month and this issue should be part of the discussion. Please make your comments here so I can see if I’m hitting a nerve.