my insurer says they would not pay for fentanyl

[GordonCook]

Letter from these creeps says.  this drug *IS* in our formulary but requires your doctor to satisfy certain requirements before we will pay for it.  So they faxed a prior authorization exception that he must fill in and send bacK.  Before i signed up with clover I asked these people fentanyl... do you cover? YES  copay is 85 dollars no mention of any prior authorization  They of course want me to switch drugs  ,,, but as we know not possible.

I don't think they will dare refuse.  But if they do refuse, then what is my recourse?

I understand i can go back to medicare (plain vanilla) if i wait no longer than feb 13.  how do i find what it willl cost under medicare part d?

I have been complaining in other questions about the difficulties of trying to go from 62 µg to 50 I spent much of yesterday paying someone to drive me to my doctor's office to get the prescription for go to CVS to fill it and to make a long story short first patch of 75 MCG went on this morning. Definitely feeling better but I had to pay $145 for the prescription for 50 MCG last week and that in effect is thrown away no refund for it in any way shape or form.

These people have been operating in North Jersey for 3 years and just moved into mercer county .   They had been doing business as path care i believe,  so far most of what they have assured me is true has turned  out to be false.

[Tuckamore]

As always you input is right on.

Drug deaths from non-prescription drugs are not declining. This" War on Drugs" has really become the War on Chronic Pain Patients. We are left without adequate pain management.

Yes, deaths are down from opiate prescription drugs - but they are on the rise in Heroin and other street drugs. Nothing was accomplished in this area - except the numbers were pushed from prescription drugs to street drugs. Suicides are on the rise in ppl with inadequate pain management. They don't count those numbers correctly. You'd be surprised how these numbers are skewed to reflect what they want them to say. But that's another story!

PMP, insurance companies and pharmacies are all jumping through government imposed hoops.

~Tuck

[caregiver222]

Tuckamore has provided excellent advice. That being said, the protocols for prescribing so-called "schedule one" drugs have become a nightmare on Elm street. This is because of an irrational populist politically motivated campaign to "reduce drug deaths". This includes the fact that starting this year prescriptions on these drugs have to be reported electronically. Filling out the "authorization" takes time on the part of the physician. And the computer reporting interface is not user friendly. Insurance companies have been faced with increasingly stringent requirements for approving pain killers with draconian penalties for non-compliance.

[Tuckamore]

Sorry Gordon! This happens way to often.

If your carrier says they will cover it - than they most likely will do so. They are buying time and trying to safe a buck. They should go back and cover any costs (within the policy limits) that you incurred because of the initial denial. However your PMP is going to have to jump through their hoops and tell them why you require the drug over another, cheaper opiate.

They may want you to take the less expensive Fentanyl.The two most popular types of Fentanyl patches are the reservoir design, and the matrix design.

Mylan pharmaceuticals makes a Matrix Patch. I believe the brand name for the Reservoir Patch is Duragestic - and the Matrix is simply Mylan.

The matrix design is inherently safer because it cannot leak gel whereas the  Reservoir Patch has been know to leak and give a dangerous, often deadly overdose of Fentanyl. You guessed it. The matrix design (Mylan) is more costly.  You also probably guessed that insurance companies want you to have the less costly Reservoir Patch.

Your PMP should also stipulate to the insurance company why you require the Martix Patch, over the Reservoir one.

In short I think, if your PMP completes the authorization correctly your Insurance company will cover it. I'd also call your carriers CS department and voice your concerns and the fact that you were mislead.

It's my understanding that though you will be able to drop your current Medicare Supplement or Advantage Plan - you may not be able to pick up another one. Medicare pays 80% of usual and customary fees. However they do not cover medications - which is why one must purchase Part D. Don't take my word for it - they may allow you to purchase just the Part D - but I'm fairly certain you won't be able to purchase a supplement or an Advantage Plan. The Medicare 800 number will provide you with the correct answers.

Contact your plan and don't be afraid to inform them you will be reporting their untruth tactics to Medicare. Things happen when you tell them your contacting Medicare.

Good luck my friend. I hope this will be resolved soon.

~Tuck