drug insurance nightmare

[jeffaok]

I have had chronic pain for 20 years. Trials with many drugs have lead to 2 that work - somewhat. They are Transdermal fentanyl patches (300mcg every 48 hours) and Actiq (1200 mcg 2x daily). My insurance company covered these until this July, when they informed me they would only cover a very small monthly dose. A new drug, Fentora, was prescribed as a substitute for Actiq, and it too was denied. While I don't receive high relief from these meds, at least some of the agony is lessened. There is no substitute for these drugs, and without them I am in constant severe pain. Without these drugs my ability to function is greatly impaired. I cannot drive and can only walk short distances, as the pain defeats me. Do any of you who need opioids have an insurance company that covers them? My meds are costing me over $1000 a month. Please let me know ASAP.
Thanks for your help-Jeff

[Mark N]

Sorry to hear of your insurance problems. I don't have an answer for you as my current insurance stinks although I need to switch over to the VA for my meds. I hope you find an answer soon and as a CPer that has fought severe pain without too many meds that work, I can feel for the situation you are in.

[Pharmacist.steve]

Insurance companies are taking a more aggressive stance on very expensive drugs. Actiq & Fentora are only approved by the FDA for CANCER patients and the insurance companies are taking the stance that these being prescribed "off-label" is experimental and most insurance companies don't pay for experimental treatment. It is perfectly legal for a doc to prescribe a drug off-label and I an assure you that they don't concern themselves about generics being prescribed off-label. To the best of my knowledge, no pharmacy submits ICD9's with Rx claims. There should be an appeal process with your insurance company .. you may have to get the insurance commissioner involved in this issue.

[brians2000]

I hate hearing someone who must suffer because their insurance company wants to play hardball. If the company wont pay for Duragesic or the generic for it maybe you could switch to something else. Have you ever tried Avinza which is a time release Morphine. I dont think it is only advised for Cancer pain because it says for Moderate to Severe pain. I used it about four years and it worked really good but when my legs swelled up with water I switched to Duragesic myself. Hopefully if insurance wont pay for duragesic you can find another med that will work and they will pay for. BTW are you on Disability? I wonder if Medicare will pay for your meds. Brian

[cindybear]

methadone is pretty cheap and a pretty good pain drug, but you have to tirate up cautiously. Also Kadian, 24 hour morphine..I was taking it every 12 hours..Worked pretty good...Medicare pays good until you get to your cut off and have to pay for all your drugs for 3 thousand dollars (where I am at now ) then It will pay 2 and 5 di\ollars for all scripts,,But by then it will be Jan, And will have to start all over again..Well I will probably have a couple of months with the 2 dollar co pays..but not many...But I think I'm going back to my husbands old drug insurance,,At least they paid all the time , all year long...With no surprises...Why I changed ???? Good Luck with what you do..Changing your meds are a hard thing to have to do for ant reason..Hugs, Cindy

[Lil E]

A lot of drug companies have programs for people that can't afford to buy their meds. I don't know if they ask if you have insurance that won't pay.

[ErinENj]

The trick I use when looking at insurance plans is to use their websites. Almost all of the larger ones have websites where you can look to see which doctors are in network, and also what meds are covered. Also, I've found that if a medication isn't on the preferred list, it doesn't mean they're not covered. My Opana isn't on the preferred list of any of my previous health insurance plans (just had my own nightmare and had to go through the amazing troubles with trying to switch them, get everything to carry over, etc.) but it was covered, and just cost more. On my current and previous plan, I paid $10 for generics, $20 for the non-generic-available meds, and then $40 for non-preferred meds. So my Opana was covered, but just cost more. I'm not sure if that works for everything or everyone, but I know Cigna and Aetna both worked like that for me (well, not 100% sure about the Aetna. Just got it and haven't tried it out on my Opana yet. Slightly nervous about that!)

If you can't find anything on their site, see if you can find some sort phone number that will connect you with someone that'll be able to answer specifically for your medications and desired plan. There are some sites where you have to know exactly which plan you're aiming for in order to get any sort of prescription plans, and then you have to know exactly what pharmacy plan comes with that (mine had about 10 different plans that weren't in any way close to clear-ish) befor you can figure out what meds are covered at what levels. So a phone call may be a bit more effective and easier to just give them a call.

And like others have said, there are a whole bunch of programs through pharmaceutical companies that will help if you can't afford their medcation, so they might help also.

[BrokenBladder]

Appeal, Appeal, Appeal!! I've heard so many good things that come out of that process. Just don't give up and good luck.:)

[Bobbi]

Jeff, you didn't mention whether you are currently working (and that's okay :)), but I found it a heck of a lot easier - if employed - and not so lonely to draw upon the skills of folks within my company's HR dept. (in the past).

Pharmacist Steve and others were just plainly a godsend. I took to heart all the ideas, and ... appealed and didn't relent.

That my doctors also didn't give up, and they are our treating physicians, also was sooooo helpful.

Something I never would have thought of, except for a job transition: If there is a different administrator over your policy you can switch to? read over its formularies. Had I done so? I could have avoided such a struggle to receive my medications as my doctors prescribe. Same insurance, but different administrator.

After going through the appeals process, I gotta say, the change in adminstrators just simplified everything so much. But, if that is not possible, get your docs to appeal... detail in writing and via phone why so the med. plan is the one for you. It is often case by case.

(Some of my medications, to be honest, are costing a lot more under the new administrator, but... I suspect that is to try "swaying" me to, again, try allergy meds. that have proved to be totally ineffective for me. The point is, though: Don't give up!)