I've got the Insurance company blues!

By Jenny Greiner Thursday, September 06, 2007

- A
- A
- A

Embarassed I just received another insurance denial letter (I have quite the collection!). This one denied the authorization for Lyrica. I finally thought that I was in the clear...the FDA just named Lyrica for treatment of Fibromyalgia, the first drug approved to treat it. My new Rheumatologist believes this drug to be the missing part of my treatment plan.

The last few drugs that the insurance denied payment for, they used the "not indicated for treatment of Fibromyalgia by the FDA" excuse. They will not pay for off label use of a drug (unless of course it comes in a generic - then it's "help yourself!"). This time they came up with a new excuse. Even though it is approved for treatment of FM by the FDA, they want me to first try at least four more other drugs (all off label - but do have a generic substitute by the way!)

I have tried three out of the four they listed, but even though they were paid for by this insurance co., I had to dig out all of the records myself. I just mailed all of the documentation off with a grievance form today, but I do not hold out much hope. My family decided to go from the HMO to the PPO last year, costing us about $15,000 extra per year, just so I could see the specialists I needed to and get all of the tests and treatments. Now I can see it hasn't really made it any easier! I don't know how they live with themselves!

The worst part of this is that the doctor gave me two months worth of samples to start on while waiting for the approval, that he assumed was comming. I feel a difference!! It seems to be helping! I have to take less narcotic pain killers!! Isn't that supposed to be a good thing? If they deny this appeal, we can't afford to pay for the Lyrica ourselves.

Any suggestions? Any luck dealing with insurance cos. about meds? I'm just about at the end of my rope, every time I take a step forward I seem to take two steps backwards!

Thanks for listening to me rant, and thanks for all of your support!

Jenny

So great to see you again Karen

Comments (7) | Add comment

Susan lic

9/ 7/07 11:28am

Most company have financial help programs so the people who need these meds can get them. May be your doctor should check into this for you. You can even go on line to find out quicker. Good luck and God bless you.

annebeckett

9/ 7/07 5:41pm

Hey, Jenny.

Yeah,my doctor also had me try Lyrica; I called the pharmac and was told that, 1. Medicare will not cover it and, 2. the lowest dose would cost me about $$150 per month!

Well, thnkfully, I guess, I developed heart pains and had to stop taking it before I actually had to PURCHASE any! See if yor doc has any sample packs in the interum; I do know that my sample bottle had about 50 (or more ) doses in it! Maybe this will get you through whil you're awaiting authorisation and cajoling the insurance co!

Jenny Greiner

9/ 8/07 4:42pm

I did ask the doc for samples, and got 2 weeks worth. Hopefully I will get the insurance to authorize the prescription by then.

I also looked at the lyrica (pfizer) web site and will check into any help from them.

I'll keep you posted!

Kiss Jenny

Mattsmon

9/ 9/07 4:12am

I just read your post and I can sure sympathize with you. I have the morphine pump and I live in dreaded fear that when I get to the age of Medicare (I have really good insurance now through my husband) I will not be able to afford the refills, either. Refills are done about every 5 to 6 weeks for me (old pump....new ones are less often) but for something that takes about 2 minutes to complete, it runs anywhere from 1800 - 2000. each time. I don't understand the why, but I know many pain providers are getting out of the pump refill business because "they don't make enough money".....I know we need major overhauls in this country as to health care, but sometimes it's just plain greed on certain doctors' parts. As for your expense, please follow up on the other comments from people---check and see if the drug maker has a program you may fall into. Also, I always see a commercial for Astra-Zenica(sp. is wrong) and I don't know if they are a drug company, but I do know several people who have obtained help for astronomical drug costs. Talk to someone in the know at Walmart......they may be able to point you in the right direction. Check for drug trial studies in your area that you may qualify for. One thing that really irks me about the so called "generic" drugs is for certain individuals, they simply do not work the same. I know they are "chemically identical", but for instance, take the drug AMBIEN for sleep. I have taken it for years and really got tired of the 40. copay so when the patent came off earlier this summer, I said "SURE--give me that ten dollar copay!" All was well until it didn't give me ONE NIGHT'S worth of sleep! I checked with friends and they ALL said the same thing. I did run into a fellow patient at my last pump refill who takes Lyrica and she said it DOES help.....did you know that the FDA is about to approve the antidepressant "CYMBALTA" for fibro? I just read that in the AMA Journal, so if you haven't tried it, perhaps it will help, too. Unfortunately, it is also $$$$

BEST OF LUCK TO YOU. Ask for samples whenever you can......as I have pleasantly discovered, most drs.' offices are more than happy to share.

Try to hang in there!

Matt'smom

Jenny Greiner

9/ 9/07 12:48pm

Mattsmom,

Thanks for your advice and support! I am currently on dr. samples and I am trying to hook up with a drug co. program.

I have tried Cymbalta (and am still currently on it). It does not seem to work as well as the Lyrica does. Strangely enough, the insurance has paid for the Cymbalta (with a $25 copay), I wonder why they are fighting doing the same with Lyrica??

Thanks again, and I'll keep you posted,

Jenny

paindrain

9/23/07 5:38am

Hey Jenny,

I was just wandering through this site and came upon your post. I, too, have chronic pain in the form of migraines. I also have bipolar disorder and it is for this condition, that I was recently denied approval of a medication my psychiatrist recently prescribed.

Part of the reality of my treatment for bipolar is being on a host of medications that make me very sleepy. After reading a post by one of the bipolar connection's expert posters, I found out about Provigil, which is a "wake-up" drug, prescribed for excessive sleepiness. I thought, "perfect", I will talk to my shrink about this and see what she thinks! Much to my delight, she absolutely agreed with me and prescribed it for the excessive sleepiness I get from taking all of the psychotropic meds. Off to the pharmacy I waltz, to get my prescription filled, only to be told, "your insurance company has denied payment of your prescription", oh and, it only costs $270.00 to fill 30 tablets of the Provigil!!

Well, I don't know about you, but that kind of money just doesn't come readily available to me, so I waited until my next paycheck and bought it anyway. It did quite a number on my budget for the next two weeks, but I was so eager to try it and to restore some degree of quality to an otherwise foggy daily life for me. And, as I hoped, it works!

In the meantime, my doctor is appealing the insurance company's ruling. Unfortunately, the source of my excessive sleepiness is the problem here. The FDA has only prescribed it for sleepiness due to 1) sleep apnea; 2) narcolepsy or 3) shift work disorder and not for sleepiness associated with side effects of psychotropic meds. So while she is fighting their ruling, I called her and told her to tell them I am working an oddball shift - 4:00 am to 12:30 pm, and maybe they would re-consider on those grounds.

Doesn't it get frustrating to go through all this mumbo jumbo bs? And it is just so hypocritical that they will pay for anything, as long as it is generic and cheap. To hell with what it is prescribed for - as long as it is cheap for them to pay.

For you, having fibro, I have read about Lyrica and I thought it should be so wonderful for you, to finally have a medication prescribed just for your condition. And then, to find out the insurance company won't pay for it! How can they get away with that?

We may not have the same condition, but we are all in this fight together, to try to get insurance companies to be more humanely responsive to our needs and not just be all about the almighty dollar.

You've got another advocate in your corner. Keep us posted on how things go. I will keep you posted as to whether or not I have any success either.

Keep the faith!

Kay

Jenny Greiner

9/23/07 3:28pm

Hi Kay Big Grin ,

Thanks for sharing your story with me, we really are all in this together. The jury (or should I say the greedy money hungry comittee deciding this rediculous case) is still out on the lyrica decision. Like you, I also was denied the Provigil. I am now on adderall xr instead (basically time released uppers) because it is cheaper. Forget the fact that it gives me the shakes and heart palpitations, just as long as it doesn't cost what Provigil does! I was given samples of the Provigil for awhile and found it to work well, with none of the side effects. I just couldn't afford to pay for it all myself.

When I was at my Rheumatologist's office last week, he was appalled that I still haven't gotten approval for the lyrica. He opened the exam room door, called all of his staff over, and asked them all to have a talk with the lyrica rep when they came to the office. I guess he thinks they should be informing all of the insurance companies about the FDA approval. I personally don't think it will help. They only care about the FDA approval when they can use it against us (as in the Provigal case).

Mad

I am sorry for my angry, sarcastic tone, but I feel like I am going to explode! It's not enough that we have to deal with our chronic illnesses, take care of our families, work to afford all of this, we also have to constantly fight the insurance companies (that we pay a pretty penny for with our premiums). Our family is paying approximately $15,000 a year more, just to get the PPO! I thought that paying for the top of the line insurance was going to be a good investment with all of my medical issues.

Sad

I'll keep you informed on the decisions, let me know about yours. Again, sorry for the tone, I'm usually a lot cheerier!!

Hope to chat with you soon,

Jenny

I've got the Insurance company blues!

Ask a Question