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.
Chris Davis set a club record last year with 53 home runs. Yet, his presence in the media now has more to do with his ADHD and suspension for the use of Adderall. This has been a set of unfortunate circumstances since Mr. Davis has ADHD which was diagnosed years ago and treated with ADHD medication. The article in the Baltimore Sun newspaper February 27, 2015 reviews and clarifies the current status with Mr. Davis and his provision for a therapeutic use exemption (TUE).
I was interviewed for the article to provide background on ADHD, medications, treatment, and the increased attention by professional sports to formalize a process by which players can be appropriately identified with ADHD and permitted to take medication for this disorder. It is my hope that professional sport leagues, international sports leagues, and college sports consider adopting a clear protocol for diagnosis and treatment according to experts in the ADHD field. In doing so, we can identify athletes without ADHD who seek to take stimulants for performance enhancement and penalize them accordingly while allowing those with ADHD to seek and follow their treatment.
You might think you’re exercising good judgment by enhancing your health and wellbeing by taking herbs and supplements. While the scientific research with replicated studies is limited, the nutraceutical companies have spent billions promoting their use. Yet now, the real problem is uncovered. The New York Times recently published a story on a investigation into herbs and supplements and found several companies whose products sit on shelves at national pharmacy chains don’t contain the ingredient on the label. UGH. Feeling trick and swindled. You bet. Read the full story here.
While I don’t discourage my patients from pursuing complementary and alternative treatments, understand that regulatory oversight and scientific research is critical in determining the real utility of treatments. Without this, marketing under the guise of education becomes the detrimental order of the day.
As time goes on, my patients are increasingly complaining about the loss of medication coverage or no longer affordable medication copays. Well, they are right and here is the proof. The following text was posted today by the American Medical Association with a link to Bloomberg News. Unfortunately, the public was never informed that the Affordable Care Act would prompt the insurance companies to change contract coverage to deny your medication that had effectively treated you for years. Health care has clearly morphed from effective treatment to contracted treatment. And this is the difference between being a patient (treatment under ethical guidelines) and being a consumer (treatment under legal parameters). Choose to be a patient first and consumer second, not the other way around.
Analysis: Benefit managers excluding more medications next year to cap costs.
In a 1,900 word analysis, Bloomberg News (11/26, Langreth) examines the trend for healthcare benefit managers such as Express Scripts to increase the number of drugs they exclude from coverage in order to keep a lid on prices. Express Script will be excluding 66 branded therapies from its main formulary next year, an increase from 48 this year, including the rheumatoid arthritis drug Simponi (golimumab). Meanwhile, CVS Health is excluding 95 drugs from its 2015 formulary.
To those of you who read this information, thank you for your interest and I hope it is insightful.
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.
If you’re reading this blog, you are one of the millions of people who now use the Internet to gain information on medical issues. In a recent survey of consumers, this is where people are looking for medical information.
Most accessed online resources:
53% web M.D.
22% Wikipedia
19% health magazines and websites
16% advocacy group websites
12% YouTube
10% Facebook
10% blocks
9% Pharma company websites
(results from third annual national consumer survey by Makovsky Health and Kelton, 2014)
I would like to take this opportunity to direct your attention to the attitude magazine website that has a large number of webinars from noted academic and professional experts in ADHD. For many with ADHD it’s often easier to watch a video on a specific ADHD topic then to read a book. While many with ADHD can sit and read for extended periods of time, it always struck me as odd that clinicians referred patients to books knowing their ability to sustain attention would be limited, especially in the evening when it medication affect us dwindled.
Explore the webinars on this site as a can be extremely helpful. On this blog site, I will continue to direct my patients in readers to reliable sources of information and clinical insights from my practice not available elsewhere.
Anticipating over 300 attendees, the 13th Annual ADHD Conference for parents, teachers, professionals and adults with ADHD on Saturday, February 22, 2014 from 8:00am to 1:00pm will feature several expert speakers. West Chester University is just outside Philadelphia. Below is the program of speakers and topics.
Marie Paxon, program coordinator, invited me to present on the science of diagnosis and treatment of ADHD in adolescents and adults. If you reside in the area, please consider attending because it is a great way to learn a great deal about ADHD quickly and network with people with ADHD and those who offer guidance and treatment. See you there.
ADHD and the Brain: Knowledge Matters Speakers
Marilyn B. Benoit, M.D. is a child and adolescent psychiatrist. She is senior vice president of Clinical and Professional Affairs and chief clinical officer at Devereux. She is a past president of the American Academy of Child and Adolescent Psychiatry. Dr. Benoit has served on the faculties of Howard and George Washington Universities and is a clinical associate professor of psychiatry at Georgetown University Medical Center, from which she received the Vicennial Silver Medal of Honor for 20 years of distinguished service.
David W. Goodman, M.D. is assistant professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. He is also director of the Adult Attention Deficit Disorder Center of Maryland in Lutherville and medical director of Suburban Psychiatric Associates, LLC. Dr. Goodman is the author of The Black Book of ADHD.
Marjorie Johnson, LCSW, PCC is a licensed clinical social worker and certified coach who provides leadership and career coaching, training, and counseling. She specializes in helping students and professionals with ADHD. Ms. Johnson serves on Chester County/Main Line CHADD’s Professional Advisory Board and is a professional member of ADDA (Attention Deficit Disorder Association.). She is past president of the International Coaching Federation-Philadelphia chapter and was named the 2011 Small Business Person of the Year by the Exton Chamber of Commerce (PA).
Jesse D. Matthews, Psy.D. is a licensed psychologist and has worked with individuals with ADHD for a number of years. He is in private practice at The Center for Psychological Services in Paoli and Ardmore and also works at Holcomb Behavioral Health Systems, a community mental health organization. He evaluates adolescents for substance abuse at the Chester County Youth Center in West Chester and does substance abuse evaluations and treatment in an outpatient program in Kennett Square. Dr. Matthews is an adjunct professor at Immaculata University. Previously, Dr. Matthews worked for six years as a counselor at Hill Top Preparatory School, and he facilitated the Chester County/Main Line CHADD teen ADHD support group for two years.
Joan M. Polka, Ph.D. is a psychologist in the Counseling Center at West Chester University assigned full time to the Act 101 portion of the Academic Development Program (a developmental education opportunity for underprepared first-time college students). She is also co-chair of Chester County/Main Line CHADD’s Adult Program and was the 2011 CHADD Educator of the Year.
Martin Patwell, Ed.D. is director of the Office of Special Services for Students with Disabilities at West Chester University. He has also been the director of evaluation clinic at Landmark School. He has presented “Trends and Issues in Disabilities in Higher Education” at Jiangxi University, Nanchung, China. He is also a consultant to The College Board, Inc.
Preeti Singh, M.S. is the associate director of the Twardowski Career Development Center at West Chester University.
Sharon Watson, M.S. is assistant director of West Chester University’s Office of Services for Students with Disabilities. She has over 20 years of experience working with students with learning differences, mental health, and physical disabilities.
8:30 a.m. Welcome
Chester County/Main Line CHADD and West Chester University
West Chester University
Earl F. Sykes Student Union
110 West Rosedale Avenue
West Chester, PA 19383
8:45 –9:15 a.m.
ADHD Across the Lifespan
Marilyn Benoit, M.D.
Research has proven that ADHD does not end with childhood. Over the course of a lifetime, the scenarios change, but the struggles might not. What does ADHD look like at each stage of life and what is the impact? This fast-paced-but-thorough presentation will help attendees learn more about this complex disorder and will provide a summary of current treatment and management options. Don’t miss this valuable session to gain a better understanding of childhood, teen, and adult ADHD.
9:15 –10:30 a.m.
ADHD and the Brain – What You Need to Know About Treatment and Management
David W. Goodman, M.D.
Those with ADHD express frustration with the disorder’s symptoms: trouble focusing, procrastination, forgetfulness, and difficulty filtering out distractions. Some people have a slower processing speed and others struggle with impulsivity. To make things even more complex, many people with ADHD will have a co-occurring condition like learning disabilities, anxiety, depression, or autism. The good news is that treatment is available, and there are strategies to counteract these challenges. Dr. Goodman will provide an overview of medications and pro-social treatments for ADHD and discuss common co-occurring conditions in this valuable presentation. Children and adults report that they receive unhelpful advice like “try harder,” “start applying yourself,” and “pull yourself up by your bootstraps.” Attend this session to learn about evidence-based treatments for ADHD and how they make a difference.
10:45 –11:30 a.m.
ADHD and Social Interactions
Jesse Matthews, Psy.D.
Social interactions can consist of anything from a casual conversation with an acquaintance to daily communication with loved ones. This can present challenges for both children and adults with ADHD. Those with ADHD may feel isolated and disconnected from others. They may find that executive function challenges can cause them to misinterpret social cues, which are usually unspoken or vague. The invisible challenges of impulsivity, forgetfulness, and an inability to regulate emotions can have a negative effect on forming and maintaining friendships. Fortunately, new information and strategies are available through the field of social learning and social cognition. Attend this session to learn more about this exciting topic and how to apply it to everyday life.
• Facilitated activity: Mindfulness Meditation and ADHD
Marjorie Johnson, LCSW
Mindfulness meditation is a way to calm the mind and relax the body while increasing the ability to sustain attention and manage distractibility. Hear about compelling research and daily applications of mindfulness meditation. Practice it to experience the deep relaxation it generates.
11:45 a.m. –1:00 p.m.
Becoming Successful in College and Early Career
ADHD and Career Success
Preeti Singh
Career development is a life-long process, involving decision making, self-awareness, exploration, preparation, and experience. What tools are available to help students successfully navigate this territory? This brief presentation will provide an overview of resources and strategies.
WCU Student Panel
Sharon Watson, facilitator
Current students at West Chester University who have “been there, done that” tell it like it is. Their transitions, challenges, and routes to where they are today provide a look at what real students face in college.
• Facilitated activity: ADD and Loving It?!
This video blends humor, hope, and science to dispel the myths about adult ADHD. Comedian Patrick McKenna seeks a diagnosis for adult ADHD and learns the facts from an impressive array of experts. Funny, moving, and transformative, this fascinating documentary will hold you spellbound!
I have been invited as an expert on ADHD to participate in an interview on the Mid-day with Dan Rodricks show on WYPR on January 27 1-2pm. This is a live panel discussion that will include Dale Archer M.D., a psychiatrist and writer, to discuss the use of medication and treatment options for ADHD. The discussion is moderated by Dan Rodricks who is a distinguished journalist in Baltimore with a regular feature in the Baltimore Sun newspaper.
Dr. Archer wrote an article online for Forbes on January 6, 2014 on his perspective of ADHD and the overuse of medication and the over-marketing of ADHD. His article highlights and echoes the sentiments of Alan Schwatz in his New York Times article “The Selling of Attention Deficit Disorder” published December 15, 2013.
This one-hour program will give me the opportunity to highlight the national and international scientific literature and research on ADHD. I hope to highlight the well documented negative consequences over the course of one’s life with untreated ADHD as reflected in several international prospective studies following ADHD children into young adulthood.
This program promises to be a lively discussion and offers listeners the opportunity to call in with questions. I encourage you to mark your calendar. I believe the program can be accessed online. If you listen, please leave me your comments for feedback.
The New York Times article “The Selling of Attention Deficit Disorder” published December 15, 2013 had quoted me towards the end of article. As I had previously written in my blog posting, the quote was taken out of context and deliberately misrepresented my professional article with Medscape. I did send a letter to the editor in order to have this quote placed in appropriate context, however, in the letters to the editor, it went unpublished. So, I’ve posted my letter to The New York Times here.
The New York Times
Letter to the Editor
December 14, 2013
Dear Editor:
Let me congratulate Alan Schwartz on his extensive review of ADHD in his article “The Selling of Attention Deficit Disorder”, December 14, 2013. He highlights the increased identification of people with ADHD and the growing use of medication as a treatment option. Unfortunately, he presents information that malign physicians and researchers who have committed their life’s work to investigating the causes of ADHD and pursuing research to prove treatments effective. Mr. Swartz would have served his readers well by revealing his a priori agenda in writing this article. A case in point, Mr. Schwartz quotes me in regards to an article I authored for Medscape on adult ADHD. In this article, he knowingly and deliberately eliminated my notation that the six-minute video accompanied a 2000 word article with 86 scientific references that extensively detailed the clinical evaluation process for ADHD in adults. Therefore my quote, out of context, misrepresents my work and misleads your readers. Perhaps his article would have been better placed in the Op-Ed section of The New York Times.
David W. Goodman, M.D.
The moral: Discern the agenda of the journalist before you make sense of the information provided. As I like to teach my psychiatric residents at Johns Hopkins, the credibility of the information is a function of the intent of the provider.
The Washington Post took the initiative to write an article in today’s (December 17) paper on ADHD in adults ages sixty and older. This article is also accompanied by a sidebar article discussing adult ADHD Older adults with ADHD are a group that has not been specifically researched and about whom very little is written. The Washington Post article includes two or three people with ADHD who were diagnosed much later in life. They speak about their lifetime experiences with untreated ADHD and the positive change they and others have noticed with treatment.
Imagine that you spent 60 years of your life distracted, disorganized, forgetful, and chronically tardy. Imagine that you have dropped out of school, lost jobs, or were divorced as a direct consequence of that state of mind. Imagine that you seek help from a professional and you are told that you have a disorder that can be effectively treated. Imagine your reluctance and hopefulness that these experiences can diminish. Imagine that you agree to treatment and discover that all of these experiences were symptoms of the disorder and not you as a person. I know, that’s a lot to imagine. At this age, the goal of treatment is not only to treat ADHD but to help a person understand the difference between what they have (disorder) versus who they are (person). In my experience helping people, this process helps resurrect a person’s self-image.
I invite you to read these two articles and seek professional help if these symptoms resonate with your experience. If you are an older adult with possible ADHD, I recommend that you see an expert in ADHD who will be able to make an accurate diagnosis. Because older adults may have both medical and psychiatric disorders in addition to taking medications, it’s critical that an expert be able to distinguish multiple disorders and evaluate the presence of ADHD accurately. Effective treatment is completely dependent on the accuracy of the diagnosis.
Thank you for your interest.
David W. Goodman, M.D.
