For People Recovering From Addiction, Insurance Rules Can Be A Big Obstacle

Twice a day, Angela and Nate Turner of Greenwood, Indiana, take tiny strips that look like colored scotch tape, and put them under their tongues.

“They taste disgusting,” Angela says.

But the taste is worth it. The strips are actually a drug called Suboxone, which helps control their cravings for opioids. The married couple both got addicted to prescription painkillers following injuries several years ago, and they decided to go into recovery this year. With Suboxone, they don’t have to worry about how they’ll get drugs, or how sick they’ll feel if they don’t.

“You can function, but you’re not high,” Angela says. “It’s like a miracle drug it really is.”  

Along with therapy, a body of evidence shows medications such as Suboxone are effective. For Angela, the treatment means she can take care of their three-year-old daughter, and Nate can keep a job.

But because of insurance rules, getting started on Suboxone—and staying on it—can be difficult.

Angela says after her doctor wrote her prescription, she had to wait three days to get it filled. She spent those days in bed with nausea, diarrhea and muscle cramps. For Nate, the wait was five days. On day three, he relapsed and used heroin.

“I just thought it was over, that I wasn’t going to make it back to the program,” he says.

It's almost like when you take on a patient to treat opiate addiction, you also have to take on another patient called the insurance company.

Suboxone is covered through the Turners’ plan, which is part of Indiana’s Medicaid expansion, the Healthy Indiana Plan. But before the Turners’ insurance company, Managed Health Services, will pay for it, their doctor has to get approval, known as a prior authorization.

The prior authorization process adds work for doctors and their staff, according to Andy Chambers, an addiction psychiatrist in Indianapolis. He says with the phone calls, faxing and other busywork, three of his nurses spend about 30 hours a week going back and forth with the insurance companies.

“It's almost like when you take on a patient to treat opiate addiction, you also have to take on another patient called the insurance company,” he says.

Getting a prior authorization can take days or weeks, says Sam Muszynski, director of parity enforcement at the American Psychiatric Association. He says the delays leave patients vulnerable to relapse.

“You may lose that opportunity right then and there,” he says. “They may never come back.”

He and policy experts with the federal Substance Abuse and Mental Health Services Administration say the use of prior authorizations for addiction medications is widespread in the U.S.

As of 2013, Medicaid in 48 states required a prior authorization for buprenorphine, the active ingredient in Suboxone. Chris Carroll, director of health care financing at SAMHSA, says that likely has not changed much since 2013. He says treatment limitations like prior authorizations are part of “the dark shadows of the insurance industry.”

Muszynski says prior authorizations are one way insurers limit what they pay for, and they use prior authorizations more often with mental health and addiction treatments, compared to other medical treatments. This is despite the 2008 passage of a law called the Mental Health Parity and Addiction Equity Act, which legislates an end to unequal coverage between diseases of the mind and diseases of the body.

These rules and regulations for us completely block the correct provision of care, and that's crazy.

For instance, under the Turner’s plan, insulin for diabetes doesn’t require a prior authorization. But Suboxone does.

“It’s just totally unfair,” Muszynski says. “There's a continuing pattern of discrimination which results in reduced access to people who need opioid addiction treatment.”

Prior authorization requirements can also pressure doctors to change how they prescribe drug such as Suboxone. Sometimes an insurer will push for a lower dosage than the doctor wants, or it will require a patient to taper off of a medication even when the doctor thinks the patient needs more time.

“These rules and regulations for us completely block the correct provision of care,” says Chambers. “And that’s crazy.”

For some insurers, a prior authorization expires after just a few months, forcing doctors and nurses to go back through the onerous process of reauthorizing. In some cases, Chambers says patients can even run out of medicine before a new prescription can be approved, which could force them into withdrawal.

Indiana Medicaid has started to allow some approved doctors to skip that initial back-and-forth with the insurance company. But Chambers says the changes haven’t helped him much yet.

Clare Krusing, press secretary with the trade association America’s Health Insurance Plans, argues that prior authorizations are not in place to limit treatment for patients with opioid addiction. Rather, they’re meant to ensure that patients receive proper care.

“Prior authorization is not just arbitrarily applied,” she says. “Plans look at what the clinical guidelines are. A plan is going to make sure that before a drug is prescribed, the patient meets those guidelines.”

She adds that the prior authorizations in place for buprenorphine don’t violate the parity law because addiction and other chronic illnesses such as diabetes are fundamentally different from each other. 

Nate Turner has managed to stay in treatment despite the prior authorization process. He says there’s an irony here: He got started on opioids without a prior authorization—in fact, on his plan, the pain pills he used to be addicted to require no prior authorization. He says he shouldn’t need one to help him stop.

“I can assure you if I was on regular pain medicine, I’d be able to get them, no problem,” he says. “No questions asked.”