understanding insurance medication denials
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?
- Obtaining your ADHD medication may grow more difficult.
- Anticipate that medication previously approved may be denied as insurance formulary tier designations change.
- Plan alternative medications with your prescriber if necessary.
- Do not accept the insurance companies’ explanation as to the legitimacy of their denial.
- 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