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have trouble getting insurance to cover pain meds?  what do you do? have trouble getting insurance to cover pain meds? what do you do?

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Unread 02-05-2003, 10:03 PM
have trouble getting insurance to cover pain meds? what do you do?

Hi! I had an interesting problem today... went to have some scripts filled. The two antibiotics (Cipro and Flagyl) were filled no problem, covered by my insurance (I only paid the $10 copay each, which is fine by me). My Vivelle dot patches were the higher copay because we specify no substitutes. However, the pain med, Toradol 10mg, was not covered at all. No explanation from the insurance company of why I have to pay $97 for 7 pills!

Sorry if I'm saying something everyone else already knew about here, but I was shocked. Anyone know why Toradol wouldn't be covered? Is there any trick to getting them to cover it, or am I just out of luck?

Thanks for any hints you all might have.
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Unread 02-05-2003, 10:14 PM
have trouble getting insurance to cover pain meds? what do you do?

Hi Linda!

I think that many of the insurance companies and HMOs are battling the drug companies about prices.

My insurance company instituted a new "formulary" policy effective January 1st. They rate drugs on 3 tiers. Tier 1 drug co-pays are $ 10, tier 2 drug co-pays are 20% of the retail drug cost and tier 3 drugs are not covered. The Zyrtec I take year round for allergies used to cost me $ 18.60 now costs me $ 93 a month. They want me to try a drug on their approved formulary list. The problem is I have tried all the others and the Zyrtec is the only one that works. I tried to file a grievence about it but it was useless. So, I shell out $ 93 a month so I can breathe...just not fair.

Unread 02-05-2003, 11:00 PM
have trouble getting insurance to cover pain meds? what do you do?

Have you inquired with your doctor about this. They may be able to prescribe more at one time so that insurance will pay for them. This was the case for me when I was prescribed Ultracet. My practicioner said that she would have to prescribe 90 at a time so that insurance would cover them under a co-pay.
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Unread 02-06-2003, 06:00 AM
have trouble getting insurance to cover pain meds? what do you do?

I'm having similiar problems I use a PPO under BCBS & like Lynn they changed my formulary on certain meds, seems to happen every year, I even have a limit now on the amount of pain meds I can recieve a month I guess I could pay the whopping $400 for that script! Sorry I cant be of more help...my Pharmacist did tell me to file a grievance w/ my Ins to try & make them make an exception for mine, exp since it was something I have been using for a couple of years... That would take time tho .....maybe file it to see if they could return your out of pocket expense?? Do you have the list of meds they will pay for? Possibly a generic for this one that they will??
Big (((hugs))) Linda I hope the meds are helping some..please keep us posted on how your doing...((hugs))
Unread 02-06-2003, 06:53 AM
have trouble getting insurance to cover pain meds? what do you do?

Often your doctor can call and appeal for you and it can be that simple. Call the insurance company and ask what the procedure is for appeals and exceptions. Often it's really pretty simple. But it's a big pain for the doctor and neither he nor the pharmacist will be jumping up and down to volunteer for this duty.

Standard, FDA-approved drugs that are expensive are often "off-formulary", but you can usually get them approved as medically necessary by jumping your doctor through a couple of hoops. Good luck with this!
Unread 02-06-2003, 07:42 AM
have trouble getting insurance to cover pain meds? what do you do?

Dear Linda

While things are different up here in Canada...I wanted to pop in to give you lots of S As I'm sure this stress is not doing you any good.

I hope you can get this figured out with the dr and the Insurance Company. This seems ridiculous to me.

Up here, I pay up front, then get reimbursed in a couple of months.

The sisters have given you some great advice...I hope you are able to get this figured out. BTW, are you okay??? I hope so sweetie. I haven't seen a post from you, but perhaps I should look again
Unread 02-06-2003, 10:51 AM
have trouble getting insurance to cover pain meds? what do you do?

Linda I'm sorry you are having promblems getting meds filled. My insurance (which I lose as of 3/1) has a formilary much like Lynn's. Then there are things that require prior plan approval, have a quanity limit, or can only be Rx by a specialist. I ran into that exact problem yesterday with the generic for Ultram -- ins. said no and 120 pills would cost me $75 and generic for Prilosec -- ins. said no and 60 pills was a whopping $229! And this is for the generics!!!! Yet, they will pay for Lortab/Vicoden/Percocet etc. at a $10 copay. Blows my mind!!! My new GP took me off the Lortab because they are known to raise BP which mine is already TOO hight now even on meds. Seems really unfair!

If your policy has a stipulation for prior plan approval, your doc might be able to get it pushed through. It's worth a try. Good luck and let us know how it works out.
Unread 02-06-2003, 11:11 AM
have trouble getting insurance to cover pain meds? what do you do?

I guess I've been lucky in that I haven't had any problems recently. My compounded hormones are even covered. Although years ago when I was on Seldane D they took that off the list and like Lynn with the med she's taking it was the only sinus med that helped me. We had a heck of a time trying to find something else that would work for me. Meanwhile my nose suffered greatly.

I may not have any problems recently because we are on a self insured plan and it's pretty open. I know that I would be making phone calls if my Duragesic patch wasn't covered.

I think it is ridiculous that they make drugs to help us to feel better and to cure our illnesses but than the insurance companies won't pay for them!

Unread 02-06-2003, 11:45 AM
have trouble getting insurance to cover pain meds? what do you do?

One more thing, DO NOT let the written exclusions keep you from asking for reviews and appeals. I've gotten prescriptions for Prevacid, which is not supposed to be allowed for more than 90 days, and for Sonata, which is not supposed to be allowed at all. They keep trying to make me take Halcion instead, which is bad for me.

Ignore the rules and push for exceptions. You may get them. At some point, the incovenience of denying you costs more than the drug.
Unread 02-06-2003, 11:59 AM

I had that happen with nexium. The ins co refused to pay for it. They said use Prilosec or the generic for prilosec and even sent a nasty letter to the prescribing physician telling him not to write rx's for nexium again.

Well, prilosec gives me EXTREME gastrointestinal problems that is a listed "possible side affect" - severe diarrhea and gastritis - so I appealed and told them that I'm "allergic" to it and suffering from that side affect. So, now they allow me to pay the same for nexium as I would the prilosec.

It took me filing a grievance through my HR rep and then to the ins company themselves, but after a few months, they finally gave in.

I agree...it's getting worse and worse. Frankly, I think the ins co's are trying to force the US govt's hand at subsidising ins rx costs.

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