This is Part 2 to a previous blog:

This brings us to the next objection insurance companies will raise – the issue of safety. In citing safety as a reason for the denial of daily stimulant doses that exceed FDA daily max allowances, they deliberately and knowingly misrepresent the meaning of FDA max daily dose. For most ADHD medications, the FDA daily max dose is established on efficacy (how well it reduces symptoms), not safety. That’s to say the FDA has decided that no higher dose brings about a better reduction in symptoms. This may be because the study didn’t test higher dosing because the pharmaceutical company didn’t want the uncertainty of what would happen at higher doses (like extra side effects).

For many stimulant medications the FDA max daily dose for adults is less than the research clinical trial submitted to the FDA. One clear example, Concerta has a FDA maximum daily dose for adults of 72 mg a day, yet the adult ADHD research trial submitted to the FDA ran the dose up to 108 mg a day. In fact, in that trial, approximately 30% of the adults were at 90 mg daily or higher. This is publically available published research data. I was a prinicipal investigator (PI) on this trial some 20 years ago. The same can be said for Adderall XR with an FDA recommended daily dose for adults at 20mg yet the adult ADHD research trial submitted to the FDA ran the dose to 60 mg a day. Again, published available research on which I was also a PI.

In my previous post on this subject, I alluded to the fact of a “physicians review of medical information”, may not have even been performed by anyone. This speculation has been recently confirmed by a medical director at Aetna. He is now on the record saying that in many cases that were denied he never reviewed most of or any of the patients’ medical records.

So, all this information begs the question “what can I do to get my needed effective medication?”
First, you’ll need to follow the insurance companies procedures. Get a prior authorization, if denied submit an appeal if you are “wedded” to your medication. One secret to the appeal process is patient involvement. While I as a physician will try to submit the most relevant and supportive medical information, insurance companies may respond with more attention if the patient is very invested in the outcome. This may work best by composing a one page letter and attaching it to your doctor’s submission of medical information. Then follow this up with a phone call that will go on the record in their files.

However, if the prior authorization is denied and the subsequent appeal is denied what recourse then? I have recommended to patients to submit a complaint to the state insurance commissioner’s office. If you are comfortable, you submit a copy of the records that were submitted for the appeal process along with a cover letter from you explaining why you are filing a complaint with their office and what action you’d like them to take. The basis of your complaint can be strengthened by your physician/psychiatrist/prescriber’s reasons that justify the medical necessity for you to remain on your medication without change in compound, preparation, or dose.

What’s the likelihood that time spent on this process will yield a positive outcome? In my experience, surprisingly likely. State insurance commissioners office tend to be protective of patients’ medical care. In the state of Maryland, the insurance commissioner’s office will forward a copy of the complaint to the insurance company who is left to respond. In my experience, in about 50% of cases, the insurance company responds with a letter to the Insurance Commissioner saying they’ve reviewed the specifics of the situation, reconsidered the decision, and approve the medication and/or dose. It is worth a try. If nothing else, the commissioner’s office keeps track of compliants.

In closing, if you are on a high dose of ADHD medication and/or on an unusual combination of medications for ADHD, anticipate having to go through this process, especially with policy and pharmacy formulary changes effective Jan 1, 2018.

Understanding and planning the steps to take if your medications come under review will help you quickly get approval and/or consider other options. This planning will decrease the likelihood of a disruption in your prescriptions and treatment. Work with your health care prescriber to navigate through the stormy seas.

In future blogs on this topic, I will cite specific insurance companies and pharmacy benefit management companies who obstruct the established and effective treatment of my patients.

Hope this helps you.

David W. Goodman, M.D., FAPA