Pharmacist Steve

[Sally Girl]

My daughter has BC/BS as her primary insurance and Medicaid as her secondary insurance.

Her neurologist prescribed Fentora for her on Saturday, on top of the Duragesic she has been on for a while.

BC/BS denied the Fentora. Her neurologist did pre-authorization on Monday. No word yet from BC/BS.

If they keep denying it (can they?), will Medicaid cover it for her? 120 doses per month.

She has been on 86 meds, and this is a last resort.

Thank you.

Cheryl

[Pharmacist.steve]

You need to get her policy out... most policies require an insurance company to answer a PA within 72 hrs.. it will be defined in her policy... Do not be surprised if their answer is NO!... that is the easiest answer for an insurance company to give.... and saves them the most money... Again, their is probably multiple levels of appeals available.. that will be outlined in her policy. I am seeing more and more insurance companies making denials for meds based on being prescribed "off-label"... Fentora is approved for CANCER PATIENTS in PAIN... so being prescribed for anyone else ... is off-label and virtually all policies exclude coverage for "experimental drugs & treatment"

I don't know what state you are in... but the state's medicaid may or may not pay for Fentora... Most likely they will have to have a denial from BS/BC before they would even consider paying for it.

I have heard of a lot of dental problems from patients using Actiq or Fentora long term.

You might want to talk to your doc about Morphine HT's... they dissolve under your tongue like Nitroglycerin... and work quickly like Actiq & Fentora. To the best of my knowledge .. doesn't cause dental problems. These HT's have been around FOREVER... there is NO BRAND NAMES... and should be a lot less expensive than other options.

Since it is a generic and Morphine is used for moderate/severe GENERAL PAIN... it should be hard for the insurance company to decline payment.

IF it was me.... I would try the Morphine HT route.... because BS/BC is going to run you around the "appeal process" for MONTHS. Every month they put you off... they will save $1000+..and Medicaid is probably not going to consider paying .. until the appeal process with BS/BC has been exhausted and they may have their own prior authorization & appeal process that you will have to go thru.

[Sally Girl]

Wow, thank you for all the advice. I was hoping Fentora would not cause tooth decay, but I believe you when you say it can.

By the way, her neurologist said there will be a third choice coming out this year--kind of like the Listerine paper thingy that dissolves very quickly in the mouth.

The amount of Fentora she is being prescribed is $4,000 a month! Plus she is on 200 mcg Duragesic, and she changes her patches every 48 hours.

We live in Minnesota, and we have very good assistance here.

This has been such a wretched experience to go through the past eight years--watching her horrendous suffering. I finally asked for help with services from the state. Her new home health nurse was here today and said the Fentora possibly could be paid for with state funds. But I want BC/BS to pay for it. I can believe they don't want to.

Thanks for the warning about how they can keep denying it. I'll get out our policy to see what it says. She is covered under my husband's policy as our adult disabled child.

And thank you for letting me know about the other med choice.

It is insane, what some meds cost. And the amount needed to make her life tolerable. We actually have not achieved that yet, despite years of trying. Brain pain is horrible pain to treat.

Cheryl

[suemck2]

FYI:
In surance policies are petty variable... but I have BCBS in North Carolina - I get 90 Fentoras a month for a copay of $100 with a diagnosis of chronic pain. In my drug formulary it is a tier 4 drug - i.e., the highest possible co-pay. Fentora doesn't have the toothj decay issues that actiq does - it dissolves much faster due to its delivery system via an effervescent tablet - think alka seltzer ...

The older version with tooth decay issues in Actiq - this now has a generic version OTFC - oral transmucosal fentanyl citrate - for me a copay of $10/month for 90 lollypops. If you're religious sbout brushing your teeth you probably won't have problems with cavities- unless you have poor chompers to begin with.

[gizmogirl]

The newer ones don't cause anywhere near the teeth problems of methadone, although you may have to live with it as an issue (take calcium and keep cleaning the mouth), since a significant % of the population has genetic support of plaque bacteria, hence more teeth problems in general.
I think Steve's advice to get something that is newer than methadone but older than what the salesmen are tellling the docs to prescribe is the best advice in the world. Since she's already not opiod naive, I think getting her enough is the important thing, not that she get the most profitable brand for the drug companies.
Good luck and get your doc on your side in this!

[fieldgoal]

FYI:
In surance policies are petty variable... but I have BCBS in North Carolina - I get 90 Fentoras a month for a copay of $100 with a diagnosis of chronic pain. In my drug formulary it is a tier 4 drug - i.e., the highest possible co-pay. Fentora doesn't have the toothj decay issues that actiq does - it dissolves much faster due to its delivery system via an effervescent tablet - think alka seltzer ...

The older version with tooth decay issues in Actiq - this now has a generic version OTFC - oral transmucosal fentanyl citrate - for me a copay of $10/month for 90 lollipops. If you're religious sbout brushing your teeth you probably won't have problems with cavities- unless you have poor chompers to begin with.

If you don't have insurance, you can go to pparx.org and fill out a form for free fentora. To meet the requirements, you have to make less than 19,200$ per year with a w-2 form. You have to document your medical history, cause of pain, what other medications you have tried. Then your doctor must document the cause, reason, and prognosis for your pain. Why he feels this medication will benefit you. I read that they recently stopped excepting new applications, but if you register at the beginning of the month, you can get approved. They will provide 120 fentora of any dosage with 2 refills every three months. Then each year, you have to reapply to the program. They also have a program for the duragesic patches, but not for actiq.IMO I have been on almost every breakthrough medication, and fentora is by far the the best to treat pain. It may not be the most euphoric, but I think it works best for btp. hope this helps

[Sally Girl]

I'm happy to report that our insurance approved the Fentora yesterday. Plus they said they were going to cover her for five more years (she is being covered as our adult disabled daughter).

We took her to the seventh neurosurgeon this week, and he has guts enough to try and help her. He is proposing up to four surgeries in a row with wait times in-between. He said to plan on being in the hospital for the long haul.

He is in Wisconsin, and we are in Minnesota. It won't be easy.

But we are so grateful someone so highly skilled and with outstanding credentials is taking her case and not just saying she has to live like this the rest of her life, like the neurosurgeons in Minnesota (including Mayo).

Cheryl

[Mark N]

Cheryl, great news about the fentora. I hope this new doctor can deliver what he is promising and your daughter has a great recovery.

[Sally Girl]

All he can do is try, and she is willing to let him. He said there are no guarantees. He said it several times during our appointment with him, and we understand.

He will start with a "re-do" brain decompression surgery.

Even if she gets 25% better, it would be worth it.

Thanks!

Cheryl

[Nana4&cntn]

Cheryl, congrats on the Fentora and the new neurosurgeon. I wish you and your daughet all the best!

Kathy