Twice a day, Angela and Nate Turner of Greenwood, Ind., put tiny strips that look like tinted tape under their tongues.
鈥淭hey taste disgusting,鈥� Angela says.
But the taste is worth it to her. The dissolvable strips are actually a drug called Suboxone, which helps control an opioid user鈥檚 cravings for the drug. 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鈥檛 have to worry about how they鈥檒l get drugs, or how sick they鈥檒l feel if they don鈥檛.
鈥淵ou can function, but you鈥檙e not high,鈥� Angela says. 鈥淚t鈥檚 like a miracle drug. It really is.鈥�
A now shows that medications such as Suboxone are effective in putting the brakes on , when used in conjunction with counseling. For the Turners, the treatment means Angela聽can take care of their 3-year-old and Nate can hold down聽a job.
But because of some companies鈥� insurance rules, getting started on Suboxone 鈥� and staying on it 鈥� can be difficult.
Angela says after her doctor wrote her a prescription, she had to wait three days to get it filled. She spent those days in bed with nausea, diarrhea and muscle cramps 鈥� the intense symptoms of opioid withdrawal. For Nate, the wait was five days. On Day 3, he relapsed and used heroin.
鈥淚 just thought it was over, that I wasn鈥檛 going to make it back to the program,鈥� he says.
Suboxone is covered through the Turners鈥� health plan, which is part of Indiana鈥檚 Medicaid expansion, the . But before the couple鈥檚 insurance company, Managed Health Services, will pay for the drug treatment, their doctor has to get approval from the insurer 鈥� known as a prior authorization.
The prior authorization process adds work for doctors and their staff, said聽, a psychiatrist and addiction specialist in Indianapolis. With the phone calls, faxing and other paperwork, he said, three of his nurses spend about 30 hours a week going back and forth with the insurance companies.
鈥淚t鈥檚 almost like when you take on a patient to treat opiate addiction, you also have to take on another patient called the insurance company,鈥� Chambers said.
Getting a prior authorization to prescribe one of these medications can take days or weeks, said聽, director of health care systems and financing with the聽. He said聽the delays leave patients vulnerable to relapse.
鈥淵ou may lose that opportunity right then and there,鈥� he said. 鈥淭hey may never come back.鈥�
Muszynski and policy analysts with the federal Substance Abuse and Mental Health Services Administration say requiring prior authorizations from insurers for addiction medication is a widespread practice in the U.S.
As of 2013, for buprenorphine, the active ingredient in Suboxone. , director of health care financing at SAMHSA, said that number likely has not changed much since 2013. He said treatment limitations like prior authorizations are part of 鈥渢he dark shadows of the insurance industry.鈥�
Prior authorizations are one way insurers limit what they pay for, Muszynski said, and they use prior authorizations more often with mental health and addiction treatments, compared to other medical treatments. That鈥檚 despite the 2008 passage of a federal law called the Mental Health Parity and Addiction Equity Act, which was supposed to end unequal insurance coverage for mental illness as compared to physical illness.
Nate and Angela Turner, of Greenwood, Ind., take the drug Suboxone twice a day to control their cravings for opioids and heroin. Nate says the drug has helped him hold onto his job and stay in counseling as he works to quit his addiction to painkillers.聽(Jake Harper/Side Effects Public Media)
For instance, under the Turners鈥� plan, insulin treatments for diabetes don鈥檛 require a prior authorization. But Suboxone does.
鈥淚t鈥檚 just totally unfair,鈥� Muszynski said. 鈥淭here鈥檚 a continuing pattern of discrimination, which results in reduced access to people who need opioid addiction treatment.鈥�
Prior authorization requirements can also pressure doctors to change how they prescribe a drug such as Suboxone. Sometimes an insurer will push for a lower dosage than the doctor wants, or it will require a patient to start tapering the use of a medication even when the doctor thinks the patient needs more time.
鈥淭hese rules and regulations for us completely block the correct provision of care,鈥� says Chambers. 鈥淎nd that鈥檚 crazy.鈥�
For some insurers, a prior authorization expires after just a few months, forcing everyone involved to go back through the process of reauthorizing. In some cases, Chambers said, patients will even run out of medicine before a new prescription can be approved, which can force them into withdrawal.
Indiana Medicaid said it has started to allow some doctors to skip that initial back-and-forth with the insurance company. But Chambers said the changes haven鈥檛 helped him much yet.
Clare Krusing, press secretary with the trade association , said聽that prior authorizations are not in place to limit treatment for patients with opioid addiction. Rather, she said, they鈥檙e meant to ensure that patients receive proper care.
鈥淧rior authorization is not just arbitrarily applied,鈥� she said. 鈥淧lans 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.鈥�
Krusing added that the prior authorizations in place for buprenorphine don鈥檛 violate the parity law, because the treatment plan for addiction is different from the treatment plan for other chronic illnesses, such as diabetes.
Nate Turner has managed to stay in treatment despite the prior authorization process. He says there鈥檚 an irony here. He started taking opioids without a prior authorization 鈥� in fact, on his plan, the pain pills he used to be addicted to require no prior authorization. He says that sort of gatekeeping paperwork shouldn鈥檛 be a stumbling block when he鈥檚 trying to quit his opioid habit.
鈥淚 can assure you, if I were on regular pain medicine, I鈥檇 be able to get them, no problem,鈥� he says. 鈥淣o questions asked.鈥�
This story is part of a partnership that includes , and Kaiser Health News.