Insurance Company Refuses to Pay For Suboxone Treatment

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One of my patients just had her insurance company refuse to pay for any more Suboxone because she has urine drug screens positive for marijuana, and because she isn’t getting any counseling anywhere. I can’t decide if I love the insurance company for taking this stand, or if I’m irritated because they don’t understand the nature of addiction. If the patient can’t afford Suboxone on her own and leaves treatment, it’s more than likely that she’ll relapse. Her risk of an opioid overdose death skyrockets, as does the risk of unemployment, physical illness, and poor family relationships.

For this blog entry I’ve changed my patient’s details to protect her identity, but essential facts are the same.

This nice young lady, let’s call her Eve, entered Suboxone treatment four years ago. At that time, she was struggling to finish college. She had been addicted to opioids for three years, and her life was speeding downhill. Her addiction started with occasional oral hydrocodone and oxycodone pills at parties, but her tolerance quickly progressed to daily use of heavier opioids. She started snorting pills. As her addiction wore on, she came into contact with other addicts who used heroin, and by the time she saw me, she was using heroin intravenously around four times a day.

She’d finished two reputable inpatient treatment centers, both for 28 days. She had no clean time after the first, and about three weeks clean after the second admission. After her relapse from the second admission, she started an intensive outpatient program, but they dismissed her from treatment during her first week because she couldn’t stop using opioids.

A few years after the last treatment center failure, she read about Suboxone online (none of the three treatment centers had informed her about it) and she was curious if it would work for her. She didn’t want to go back to inpatient treatment because she was now in college, though on the verge of failing all her classes.

She started Suboxone in 2008 and has never had a positive drug screen for opioids other than Suboxone. However, she self-reported one relapse a few years ago, when she went to a party with an old using buddy. The relapse lasted one day, and she told me about it at her next office visit. We took that as an opportunity to talk about triggers for drug use.

Every drug screen over the 4 ½ years I’ve been prescribing Suboxone for her has been positive for marijuana. She talks freely about her marijuana use and sees no problem with it, saying, “At least I’m not still shooting heroin!”

She began individual counseling when she started Suboxone, but after the first six months she gradually missed appointments, and finally said she lacked the time and money to see the counselor. She then went to 12-step meetings at my insistence, but never liked them, or felt a connection to the people she met there. After the first few years on Suboxone, she stopped going.

In college, her grades improved dramatically and she was on the dean’s list for a few semesters in her last few years. She graduated in five years with a double major, to her skeptical parents’ amazed delight. She got a job and within a year became the company’s top performer. She just got engaged to a man who does not use drugs.

We have slowly tapered her dose of Suboxone over the last few years. Initially on 16mg, she now takes half of a 2mg Suboxone film, or 1mg per day.

At this point, some of you are saying, “Why did you allow her to stay in treatment, since she still uses an illicit drug and refuses to get necessary counseling? Kick her out of treatment…she’s violating her treatment contract.”

And others of you are saying, “Thank God she’s on Suboxone. She’s not injecting heroin, she’s doing well in life, and if you continue to work with her, she may stop marijuana use as well. Even if she doesn’t, she’s doing so much better it would be immoral to stop prescribing Suboxone for her.”

I know you readers are thinking those things because I’m thinking those things, every time I see her. She’s so dependable with the Suboxone that I’ve cut her visits to every two months. I’ve done pill counts, and I don’t think she’s misusing her medication. And at each visit, we talk about marijuana. I’m using motivational interviewing techniques, as best as I can, to try to allow her to look at all angles of her marijuana use. I do acknowledge that it causes less harm to the body than the alcohol that she was able to quit completely, but remind her marijuana is still illegal. Even if it weren’t, it can cause problems all its own, particularly in someone with an addiction history.

She used THC daily for many years, but has reduced her use. During college, she admitted it interfered with memory, so she used mainly just on weekends. Now out of college, she smokes marijuana with friends one or two times per week. Her company doesn’t do drug testing, but her fiancé is annoyed when she smokes. She admits that if she ever wants to have children, she’ll have to stop smoking, but otherwise sees no problem with her use of marijuana. She won’t consider further counseling. She says she doesn’t need it, because life is going well, and it didn’t help her in the past. She’s relatively happy and content with her life.

She’s the picture of harm reduction.

Now her insurance company has given her another good reason (financial) to stop using marijuana, and to go back to counseling. On one hand, their decision could be enough to convince Eve to stop using marijuana. Smoking marijuana and declining to get further counseling may cause such a financial burden that she’ll change her mind about both. Or will it force her to quit Suboxone completely? And what would happen then?

What if Eve was an overweight diabetic who refused to diet or exercise? Should her insurance company pay for an expensive medication to regulate her blood sugar? I’ve never heard of an insurance company doing such a thing, yet is there a difference?

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7 responses to this post.

  1. Posted by Cheryl Kupras on January 6, 2013 at 1:43 pm

    Excellent! Yes, addiction is still not thought of as a Chronic Disease. Keep fighting!

    Reply

  2. She has finished college and now has a job !!! YES SUCCESS!! As the years go by these insurance companies do get tighter with the “benefits” I do not see how it is, in light of the science based evidence that MMT,ORT, BUP, are effective treatments that an insurance company would pay for a Patient to go to a 28day in patient re-hab but yet prevent/make it Oh so difficult for the Patient to get ORT. ? A Patient could have multiple years of ORT therapy for the cost of an in Patient re-hab stay!! When you actually see the statistics/rate of success vs cost for in Patient re-hab it should not be difficult to see the benefits of ORT.. Any chance this Patient could get a prescription for the thc?? or if she does not think she can stop thc she may well have to make a choice and pay out of pocket. That does pose an excellent question , Patients who refuse to quit smoking ciggareetes who then have copd/ lung disorders/cancer , should an insurance company be forced to cover treatment?? Diabetics who eat food that causes thier blood sugars to rise/refuse to exercise , should they be forced to comply or not covered.. I do understand that thc is illegal and it could cause serious legal/financial problems for her, def. something that she should weigh in the equation of her stability now?? Difficult questions , but she has progressed and deserved treatment..

    Reply

  3. Posted by Amanda on November 1, 2013 at 9:20 pm

    SUBOXONE is a Miracle drug! Medicaid is getting stiffer and doesn’t want to pay but for so many. Each state has a requirement on how many a patient can have dose wise and all..check that out also quite interesting. All states have Board of Pharmacy prescription monitoring programs and if you have Medicaid they will request a detailed plan on the patient which requires every month review of drug screens, counseling or group therapy or online groups are excepted. They want all this clinical history to know your not abusing the program but mostly to see that it is actually helping you (the patient) bec so many are not taking it serious and are selling them which hurts the ones who are really being helped by this drug like me and my little brother. It makes me so mad that they want all this and literally you have to wait on PAs all the time in order to get your meds but what can we do when its Medicaid?? also you can request the suboxone card helps ones who cant afford it. You don’t need a Dr to give it but your Doctor should give you one if you request it or go to SuboxoneFilmCoPay.com it covers more than 50$ a month r more depending on your situation.. Also go online I found other programs to help pay for them. Only you can use the card not anyone else who receives them so be very careful if you considering loaning it DONT! ANYHOW to your question yes her ins should pay for her Medications period whether Diabetic or Opiate user trying to clean up on Suboxone and she needs to see a dr who performs drug test in his office not through a company that does the Mass spectrum and there r plenty of Drs who are kool w the use of Marijuana bec its an herb all natural then again he’s a holistic dr so he’s kool… the doctors that perform drug test in the privacy of their own clinic usually want submit she’s smoking Thc and send it in,,,I say change doctors or ask wha’ts their routine in drug testing when you pay the fee to c the dr ask does he send drug results off to some other lab or does he do them privately in office, My doctor is kool w the Thc he just doesn’t send that part in….and half the patients smoke and r on Suboxone think its the Dr you choose. Medicaid is trying to pay for less and less on this medication bec its gotten popular and i’m sure all states hate it and police and judges and so forth they will take it from us in the end or come up w some sort of bs to end it on market r cause drs to write less and why I believe its starting to happen already is another story but it keeps addicts clean & Alcoholics and not on dope so less money to the courts bec officers don’t have anyone to arrest round my parts bec this drug has actually kept a lot or I say millions off the streets bec they r clean now.. you would think they do all they can w anyone trying to stay clean and as long as shes clean w just the herb and BUP in her system I don’t see what the hell it matters! she needs to write a letter to the Department to where ever her ins is or Medicaid to show proof and her own story of how its helped her to stay clean and whats going on trust me someone high in that department will help? If I knew who her ins peeps were I could tell her or help w giving her an example of how but in her words not mine, sorry!! but stay proud hold your head up sweetie, things will work out so don’t give up.

    Reply

    • Can’t say I disagree with most of the points you make, except that: -your doctor is committing Medicaid fraud by lying about drug screen results -today’s marijuana is about as natural as today’s cocaine, alcohol, opium.
      Marijuana has been bred and crossbred in order to increase the THC content. This ain’t your mama’s weed…it’s high tech stuff.
      It causes less physical harm than other drugs, and many people use without problems, but if you have the disease of addiction, it changes everything.

      Reply

  4. Posted by Suzie on December 20, 2013 at 8:19 am

    I know exactly what she is going through. I had been addicted to opiate for about 5 years. I then found out I was going to have a baby and I knew then I had to do something so I told my doctor I had a problem. I was put on suboxone I took and still take 8mgs film 3 times a day and I know that if it wasn’t for being put on suboxone that my perfect little boy wouldn’t be here today so even though at times I wish I didn’t have to be I thank god that there is something out like suboxone to help people. I have had the same problem though with my insurance paying for it not BC of any drug test but BC it cost to much. I’m thankful to have it but at the same getting off of them is no easy task and when I don’t have them I get so sick. Great job to Eva for not giving up and pushing on

    Reply

  5. Posted by Getting Better on February 23, 2014 at 7:25 pm

    Unfortunately, views and opinions regarding addiction vary greatly from person to person….. traditionally, those whom have NOT experienced addiction, often see it as a simple “choice”, where those whom HAVE experienced addiction (and/or live closely to addiction in some other way), feel very differently…….. It sounds like her insurance company wouldn’t relate her situation to that of an overweight diabetics, because they’d believe an overweight diabetic couldn’t as easily “choose” to make themselves better, like an addict probably could…. Now as an addict myself, I’m 100% sure that my illness is NOT chosen… Nobody CHOOSES a life of misery… Our problems are beyond our control, just as the overweight diabetics problems are beyond their control. Like I said though, addiction is too often seen as a “choice”, by those with limited knowledge/experience…… On another note: It’s entirely insane to me, that insurance companies can (in a sense), overrule DOCTORS…. by refusing to pay for the medication, they’re almost saying the patient doesn’t NEED the medication… That’s a whole different subject of it’s own, but neverless an important one, that I feel gets WAY less attention than it should….. How is it, that an insurance company, who knows a patient only by a number, feel they’re opinion, could somehow be correct over a patient’s doctor, who sees them personally, on a regular basis??? Seems absurd to me….

    Reply

  6. Hi Everyone, I am going through this right now. This is why i found this blog. I have been successfully using buprenorphine/naloxone for close to 2yrs now after having been using heroin and crack for about 10 years. Within those years I have been to many programs. Anyway, these medications are the first thing to actually work, where I can be productive and function as a person without this ailment. Inpatients, NA, or AA have been largely ineffective(i also don’t believe they have any truly conclusive positive tests)

    Similarly, I smoke weed. I have found that it is something that I enjoy, that I use for many reasons, and it does not threaten the positive course my life is on.

    Increasingly, my insurance has been making it more and more difficult with many prior authorizations, and calls to the health insurance company. These uncaring individuals have hung up on me several times.

    Due to the fact Zubsolv is their “preferred” medication, I am trying to obtain that. For some odd reason, it wasn’t the same pointless back and forth until my medication was received. Now I am being asked to provide a urine sample. I am worried that they will make it a simple decision and just deny me based on marijuana use.

    Thanks everyone for adding to the conversation and janaburson for creating this post.

    Reply

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