Humana's End Run to Deny Buprenorphine Coverage

Humana Health Insurance recently revised their guidelines to ultimately reduce the number of scripts for Suboxone that they will cover.  I am in the process of writing the Humana Grievance Department a letter to regain coverage for a patient who was doing very well on the medication.  To provide context, last week I learned of a former patient who had stopped buprenorphine for his own reasons, who passed away a few months later from on overdose of heroin.  And then this morning a patient told me about her nephew, who at the age of 16 is in a coma after an overdose yesterday.
Buprenorphine has the power to prevent these and other deaths from opioid dependence.  But patients must have access to the medication.  Many barriers exist;  doctors are reluctant to prescribe, afraid of their practices being open to random DEA audits, unwilling to take on the additional paperwork, or not interested in attracting an ‘unsavory element’ to their practices.  And buprenorphine-based medications are too expensive.  A cost of $6-$12 per day sound reasonable for a life-saving medication, but $360 per month is a large expense for someone with piles of debt, trying to make a new start.
Then there is insurance. This is a case where good policy from insurers will literally save thousands of lives.  But Humana, by playing doctor, will do the opposite — i.e. cause the deaths of many people.  I’m sure this sounds like an exaggeration– like I must be using scary words to make a point?   I wish that were the case!  Humana is playing with just enough knowledge of science to deny claims– and in THIS situation, make no mistake– the result will be dead teenagers.  Don’t kid yourselves, Humana.
This gets a little complicated…  and while I think of it, please consider forwarding this to your local newspaper, just in case somebody with access to the press wants to save some lives.
The patient of reference has been doing well on buprenorphine for a couple years.  In January, Humana changed their policies such that the medication is no longer covered.  The patient cannot afford to purchase the medication out-of-pocket– after all, that is why he pays for a good health insurance policy!    Humana didn’t just remove buprenorphine completely, as that would have resulted in lawsuits that they would have clearly lost.  Instead, they used various drug interactions to make people ineligible for the medication, under the guise of ‘good medicine.’  The problem with this approach is that we docs know that nowadays, virtually every medication out there interacts with other medications.  We all have computer programs or reference texts to quickly sort out these interactions.  And when interactions are found, we don’t just drop the medication; we use our knowledge of biochemistry and pharmacology to prescribe safely– sometimes with different medications, and sometimes with different dosages of the same medications.  That is why medical school lasts four years!
The denial states ‘to meet medical necessity guidelines for coverage, the member must meet the following criteria:  member is not concurrently using ANY narcotic painkillers, methadone, azole antifungals, protease inhibitors, macrolide antibiotics, benzodiazepines, cimetidine, or sodium oxybate.  This coverage determination was based on the Humana Pharmacy and Therapeutics Buprenorphine Containing Products Coverage Policy.
I will paste my appeal letter to the insurer below;  the letter will explain my problem with the insurer’s policy.
Dear Medical Director,
I am writing to appeal the denial of coverage for buprenorphine for maintenance treatment of opioid dependence for a patient in my psychiatric practice, Mr.  XXXXXXX. Mr. XXXXXXX has been treated using buprenorphine for the past year, and has done well with this treatment, with no episodes of relapse.
The denial letter includes what is described as Humana’s Pharmacy and Therapeutics Buprenorphine-Containing Products Coverage Policy, but does not specifically identify the reason for my patient’s denial.  For that reason, I will address several issues that are included under your stated policy, after first addressing an issue that is not part of the policy, i.e. length of treatment.
Length of coverage for buprenorphine maintenance
I assume that coverage is not being denied for reasons related the period of time for treatment with buprenorphine. More and more studies establish that buprenorphine should be considered as a maintenance medication. I personally am aware of several deaths of people with opiate dependence after their discontinuation of buprenorphine. I understand the temptation to think that at some point, people should do well without the medication. But research has clearly shown that opioid dependence is a chronic condition that warrants chronic treatment.
The Humana Pharmacy and Therapeutics Buprenorphine-Containing Products Coverage Policy
I am well-versed with treatment using buprenorphine. I understand the fear of respiratory depression from combining benzodiazepines and opioids. I am familiar with drug/drug interactions caused by effects of some medications on hepatic enzymes. These and other issues are commonly considered and managed when prescribing medications for other disease processes. I would hope that physicians are allowed the same discretion and clinical judgment when treating patients with addictions, as when treating other conditions. The issues of drug/drug interaction and additive respiratory effects should not be considered absolute contraindications—particularly given the lack of other effective treatments for opioid dependence, and the ease with which such issues can be managed by a knowledgeable physician.
Benzodiazepines
The danger of combining benzodiazepines with buprenorphine occurs when a patient is not tolerant to the mu-receptor effects of buprenorphine, and is given an additional respiratory depressant. Once a person has become tolerant to buprenorphine, the danger from respiratory depression from benzodiazepines becomes the same as in a person not taking buprenorphine. I have testified in two cases of deaths from buprenorphine and benzodiazepines; in both cases the person had no tolerance to opioids or to benzodiazepines. Even in the absence of full tolerance, combined use requires consideration but is not an absolute contraindication.
Zolpidem
I do not know if your policy considers zolpidem (Ambien) to be a benzodiazepine; the molecule has actions similar to benzodiazepines at GABA receptors, but zolpidem is not a benzodiazepine, as it lacks the benzene and diazepine rings that define the benzodiazepine class of molecules.  At any rate, non-benzodiazepine GABA hypnotics can be used safely in people taking buprenorphine for the same reasons as described for benzodiazepines.
Cross-Addiction
When considering using any potentially-addictive medication in a patient with a history of addiction, consideration must be given to the risk of cross-addiction. This consideration applies to the use of benzodiazepines and other sedative/hypnotics.  Deliberations over the risk to benefit ratio in such circumstances has always been part of the work of physicians treating addictive and psychiatric disorders. This need for deliberation does not imply an absolute contraindication to concomitant use of buprenorphine and benzodiazepines.
Opioid Agonists and Pain
Your policy states that buprenorphine will not be allowed in patients receiving narcotic analgesics. But from time to time, patients on buprenorphine maintenance will require surgery, will suffer from trauma, or will have painful dental procedures. The treatment of acute and chronic pain in patients on buprenorphine has been studied extensively, and a significant body of literature supports the use of opioid agonists in people taking buprenorphine. As an aside, combining buprenorphine with opioid agonists works so well that I have no doubt that combination treatment using buprenorphine and agonists will eventually be recognized as the best way to administer opioid analgesia while reducing the risk of dependence.
Your buprenorphine policy allows no opioid analgesia for patients on buprenorphine who become injured or require surgery. What do the writers of your policy expect people on buprenorphine to do in the case of surgery? If a patient has pain that requires an opioid agonist, will that patient lose insurance coverage for the only truly effective treatment for opioid dependence?
I have treated post-surgical pain for patients on buprenorphine using opioid agonists as recommended in the literature. I have included an excellent review article that describes the technique.  The article includes references for studies of combining buprenorphine with opioid agonists for pain management.
(http://suboxonetalkzone.com/bupe.pain.pdf)
I do not plan to prescribe opioid agonists for Mr. XXXXXXX.  But the writers of your buprenorphine policy should be aware that there are patients who require long-term opioid analgesia, who at the same time benefit from an anti-craving medication. It is simplistic and scientifically naïve to believe that one should automatically disqualify the other.
I ask for a resumption of coverage for the prescription for buprenorphine for Mr. XXXXXXX. If that coverage is not provided, I ask for the specific reason for disqualification. I will continue to aggressively advocate for Mr. XXXXXXX, and for his right for treatment under the terms of his policy. He is already struggling with a potentially fatal illness. At the very least, he deserves coverage for the one effective medication for his condition.
I’ll let readers know how things turn out.