Drs. not allowed to prescribed certain meds for FMS.

I have had FMS and CFS since 1993.  In addition, I have depression, GERD, IBS, and arthritis in my lower back and left hip.  I have been disabled since 2003.  Prior to 2003 I was taking one medicine for my GERD, Paxil for depression and hydrocodone for my FMS (the arthritis was not diagnosed until recently).  When the pain elevated to the point I could no longer work my physician (FP) took me off hydrocodone and put me on Duragesic patches daily, and Actiq lozenges to be used as needed.  He also added Lasix  to my regimen because my ankles and feet were very swollen and I was also put in a wheelchair to help with mobility.  These made a considerable difference in my pain control and allowed me to become more active.  The first summer on disability I had surgery for carpal tunnel syndrome.  The FMS pain worsened so I was put on oxycodone and Valium.  Both were to be used on a regular basis.  Overtime I have come to manage my medication and am cutting back on the narcotic medication as much as I can.  However, the Duragesic patches will be the last to go, according to the recommendation of pain management specialists, and we are working on pulling me off the other narcotics.  At this point, I use the Actiq lozenges for those situations when pain is unbearable and I need quick relief of the pain which pills cannot offer.  

I am sorry for overloading you with background, but you should also know that I had a bout with pancreatitis a few years ago.  My physician was not on-call when I went to the hospital that Friday at 5:30 p.m.  I was admitted quickly and the physician covering for my doctor did not write prescriptions for narcotics.  Therefore, she didn't understand how to manage my care at all.  So, Friday night at 9 p.m. she took me off ALL my narcotics and placed me on a morpine pump which did nothing for the pain.  By Sunday I was in withdrawl (withdrawal) and I couldn't get anyone to understand what was happening.  They considered me a problem patient.  It wasn't until my physician returned on Monday that I was taken off the morphine pump and allowed to go back on my medications.

All that being said, we are running into a situation again, which we ran into with another insurance provider my husband's office contracted with.  After being with this company for over a year now, they have changed their guidelines and will not allow anyone to take Actiq (or its generic) unless they are cancer patients because that is FDA-approved use for this medication.  However, I have spoken to the FDA and they do not have a problem with physicians writing scripts for this medication for non-cancerous conditions.  They say it is ultimately up to the physician.  But the insurance company says it doesn't matter that my physician PRESCRIBED this for my pain, which is severe.  They won't budge.

Here is my question:  How can insurance companies get away with not allowing a physician to write prescriptions and have them filled when they are the ones who see the patients, knows the pain and the specific situations in the patients' lives,  Also, is there anyone who can help with this, short of getting an appointment with the President of the United States?

[VaBreeze]

"ACTIQ is indicated only for the management of breakthrough cancer pain in patients with malignancies who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. Patients considered opioid tolerant are those who are taking at least 60 mg morphine/day, at least 25 mcg transdermal fentanyl/hour, at least 30 mg of oxycodone daily, at least 8 mg oral hydromorphone daily or an equianalgesic dose of another opioid for a week or longer.

ACTIQ is intended to be used only in the care of cancer patients and only by oncologists and pain specialists who are knowledgeable of and skilled in the use of Schedule II opioids to treat cancer pain."

http://www.actiq.com/

Unfortunately, this site does not say that this medication can be used for other pain management.  Insurance companies can include what they will or will not cover, based on the type of policy you have and what is an allowable charge.  Just because a physician writes a prescription, doesn't mean insurance will cover it.  

You can contact your State Corporation Commission's Bureau of Insurance and file a complaint.  They handle insurance companies involving a change in criteria (ie. not covering what was once covered or the necessity for a service).  It would help if your physician wrote a letter to validate your necessity of the medication in treatment for your pain management.

You can file online or give them a call to talk about your best approach.  

I wish you the best of luck.  Take care.