OptumRx Denial Insanity

I have treated a patient with a history of opiate addiction for close to ten years with buprenorphine maintenance with no relapses. I have reviewed the case with OptumRx for authorization of reimbursement for the drug a few times, typically about every 6 months. After the last telephone review OptumRx denied reimbursement. Apparently they even refused to tell their subscriber who asked me to pass on the information when -- or if -- I should receive it.

I have no contract with any payer or pharmacy benefit plan. My role as physician should consist of diagnosing illness and recommending treatment -- not obtaining reimbursement. And not acting as the messenger for a payer. If my own health insurance company refused to give me that kind of information I would complain to the state insurance commissioner.

In a moment of weakness I acquiesced and informed the patient: I received a letter from OptumRx (I refused to provide my fax number.) indicating justification for denial of reimbursement: The patient is not "in counseling." This from a pharmacist.

Never mind that the patient neither wants nor needs counseling. Never mind that pharmacists have, as far as I know, no training in psychotherapy or counseling. We know she just found the item on a list, perhaps entitled "Excuses avoiding payouts." Never mind the absence of any definition of the term counseling or any indication of how long this should go on or how one establishes need for the treatment. The implication: To get the drug you must "be in counseling." Anything from psychoanalysis to Transactional Analysis might suffice. OptumRx does not say.

The patient has dropped out of treatment. Maybe Obamacare will restore some sanity. I doubt it.

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