Doctor: Insurance companies not allowing higher dosage exception

BEL AIR, Md. - Mandi Pullen has been clean for eight years. But her battle isn't over.

"It's very hard some days to get up and do what I have to do. Just to get up," she said.

She's getting up knowing she's not getting the dosage of Suboxone she needs to function. It's a medicine commonly prescribed for opioid dependence -- addiction to prescription painkillers or heroin.

"We all like to think that abstinence based programs work, but for opioid dependence, they just don't," said Dr. Lee Tannenbaum, an addiction specialist. "The current theory is that when people damage their brains opiates, some of that damage may be permanent."

Tannenbaum said it's been a struggle to get the right dosage covered by insurance. He said the drug's manufacturer suggested a maximum dosage that is lower than what Pullen needs. Her insurance company is only covering what's recommended.

"It's an incredible difference. The difference between the right dose and the wrong dose means the difference between a functional life and a non functional life," Tannenbaum said.

He's sent in Pullen's patient log, called the company, and wrote letters to no avail.

"When the doctor says that you need something, they should be there and more than willing to say, 'Okay, if this is what the doctor says you need, then this is what you need. Not what we say you need,'" Pullen said.

It's an issue the National Alliance of Advocates for Buprenorphine Treatment has seen time and again.

"I think the insurance companies need to not practice medicine. And leave that between the doctor and the patient," NAABT President Timothy Lepak said.

Lepak argues that dosing caps don't make any sense because the amount each patient needs is different.

"I remember one patient telling me that the most stressful point of their week or month is when they're going to the doctor and they're waiting for their pre authorization to go through," he said. "That they're worried sick that this is going to be the day that it doesn't go through and they're going to have to-- they're not going to be able to work, they're not going to be able to take care of the kids; everything is going to change."

But Dr. Edmund Pezalla with Aetna says there's definite potential for doses to be covered case by case depending on the patient.

"The rules were created in order to manage safety as well as appropriateness of prescribing and use," Dr. Pezalla said. "We're not, for example, telling a patient that they should take one dose over another dose. That is, indeed, something only a physician and patient should work out. However, the dosing limits or quantity limits that carriers place on medication are reasonable."

He says under Aetna policy, they review the materials from the FDA on the approval of the drug and the drug licensing. They also look at trials that were done. Typically, he says, they set doses to meet maximum dosages allowed during the trials or doses that will serve more than 95% of the population.

We reached out to the major insurance companies for comment on their policies. Aetna is the only company who got back to us. They are not necessarily the company Pullen uses. Aetna says the rules were created in order to manage safety as well as appropriateness for use.

Tannenbaum says he's been working for ten years taking his argument to seminars and trying to prove that different patients have different needs.