I have written about the sleazy actions of health insurer Humana.  Today I filed a formal complaint with the Wisconsin Commisioner of Insurance regarding their practices.  I’ll copy my letter below, rather than take the time to write everything over again.  If there is an attorney willing to work the case on contingency, please contact me.  Likewise, if other patients or physicians are having similar problems with Humana, send me an e-mail through my website at www.fdlpsych.com.
The complaint:
My patient, XXXXXX, has been treated for opioid dependence for two years, using maintenance treatment with Suboxone.  He has maintained sobriety from opioids.  He also suffers from panic attacks and takes Effexor daily.  He uses lorazepam, a sedative, several times per month, and takes a sleeping medication, Ambien, most nights.
The standard of care for treating opioid dependence with Suboxone includes long-term use of Suboxone, particularly in young people (Mr. XXXXXX is in his early 20’s).  Mr. XXXXXX was fully compliant with treatment, including attending weekly psychotherapy and avoiding illicit substances.
In December of 2010, Humana stopped covering Suboxone for XXXXXX.  When I wrote to the company and asked for an explanation, I was told that he was denied because he did not meet the criteria of the company’s ‘buprenorphine coverage policy’.  This new policy was introduced without warning, and stated that people would not be covered if they were prescribed ‘benzodiazepines’ like lorazepam.
I appealed the decision by Humana, stating that the lorazepam was important for treating Mr. XXXXXX’s panic disorder.  But I wrote that his life depended on buprenorphine (Suboxone)– so we would stop the lorazepam immediately so that he would fit their ‘buprenorphine coverage policy’. 
The company continued to deny coverage.  I wrote again, asking for an explanation, and they wrote that Mr. XXXXXX was not eligible because ‘he was taking the benzodiazepine Ambien.’  I noted that Ambien is NOT a benzodiazepine, and does not therefore violate their policy.  But again, I wrote that I would not debate whether Ambien was or was not a benzodiazepine, but instead we would stop the Ambien, given the importance of Suboxone to the patient’s life and health.
The company again denied coverage through the appeal process, writing that ‘maintenance treatment for addiction was not indicated.’  Humana did not explain WHY his addiction treatment was not indicated.  I note that many patients receive buprenorphine for years, and the death rate from untreated opioid dependence is significant and well established.  I appealed the decision, asking for the name of their medical director.  Humana refused to provide the name, even after I called their offices repeatedly.  They continue to deny coverage, and today Mr. XXXXXX received notice that his final appeal was denied.
In summary, Humana was covering maintenance treatment for Mr. XXXXXX’s opioid dependence using Suboxone.  They then abruptly stopped coverage.  Mr. XXXXXX was forced to go through withdrawal without any warning–to him or to his physician–placing him at great risk of relapse and death.  When I attempted to re-establish his coverage, Humana wrote that they had instituted a ‘buprenorphine coverage policy’ without any prior warning. The policy is arbitrary and discriminatory, essentially stating that patients who are treated for opioid dependence are not eligible for treatment of other mental disorders, including panic disorder.
Finally, Mr. XXXXXX was willing to give up treatment of panic disorder in order to receive Suboxone—a medication that is vital to his continued sobriety.  I have repeated notified Humana that Mr. XXXXXX now complies with their arbitrary coverage policy– yet they continue to deny his claim.
This is a very dangerous situation.  Patients who are taking buprenorphine can do very well when compliant with treatment using Suboxone.  Humana pulled the rug out from under Mr. XXXXXX without warning, suddenly denying the medication, and then refusing coverage even when the patient clearly met all criteria according to Humana’s own unfair, arbitrary coverage policy. 
At minimum, Mr. XXXXXX should have his coverage for buprenorphine resumed.  Humana should be punished to prevent this dangerous, discriminatory behavior from hurting other patients.


tic · April 15, 2011 at 9:04 am

Since Lorazapam and Ambien are available as relatively inexpensive generics, the patient could continue to take them and just pay cash for the scripts. Then Humana would not be aware of benzodiazapine and “psuedobenzodiazapine” use. Of course this would not help with the maintenace treatment with suboxone. I wonder if Humana would provide coverage if the patient relapses on narcotics.

Selena · April 22, 2011 at 10:51 pm

I’m so pleased to see this article. I’m having the same problem with Humana. I was denied coverage as well. I’m appealing it. They said I was not to be covered b/c I was on narcotics. I tried to tell them I’m no longer on them and I need this so I won’t take the opiates. Three years ago they paid it with no problem. Since then I have had several surgeries and the addiction of course kicked in again. I’ve had to pay for a weeks supply. There is no way I can pay for anymore. This is wrong. They had no problem paying for my many scripts of narcotics and now that I want to get off them they are trying to prevent me from doing so. This is WRONG.
After reading this article I’m in a panic over this. I have had a history of seizures. I would think if that was to happen and they have to hospitlize me it will certainly cost them awhole lot more. By the way,who are they to say no to what a Dr. has said that I need?
I’m wondering if I was to try to go to the Suboxene Lab if they could help those of us that can not afford to pay for this. We not talking a few dollars here,it is very expensive.
I’m going to continue to come back to this article with hopes of finding a possible answer.If I find one I’ll certainly be back with the status of what is going on.
Thank you so much for putting this out for others to see.

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