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Old 11-27-2012, 05:43 AM   #1
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Question about insurance and what they will pay for as far as my pain meds

Hi everyone,

My doctor has put me on Oxycodone 10mg, 4x/day. I've been having to pay cash for it b/c the pharmacy said the drug at that dose is not in their formulary. I asked and found out they will pay for the 5mg Oxycodone. Should I ask my doctor to write for the 5mg, and just double up to get to to 10mg (with his recommendation of course!)... just wasn't sure if anyone else has run into this and how you and your doctor handled it.

I found an online discount pharmacy card that I've applied for to see if they are able to help with this too.

Thanks all!!

 
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Old 11-27-2012, 07:34 AM   #2
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Re: Question about insurance and what they will pay for as far as my pain meds

Hello Pandie and welcome.

There are certain insurance companies that will make an exception and cover on the dosage and/or medication, (even though it's not on their formulary)if the doctor calls in and explains the situation.

Hopefully this applies in your case.

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Last edited by Phoenix; 11-27-2012 at 07:39 AM. Reason: additional wording

 
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Old 11-27-2012, 07:41 AM   #3
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Re: Question about insurance and what they will pay for as far as my pain meds

Thanks Phoenix. I see my doctor on Thursday and will ask him about it. I've been unemployed for one month and trying to save where I can. Otherwise, it cost me right at $100 for a months supply :/

 
Old 11-27-2012, 08:01 AM   #4
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Re: Question about insurance and what they will pay for as far as my pain meds

Quote:
Originally Posted by Pandie View Post
Thanks Phoenix. I see my doctor on Thursday and will ask him about it. I've been unemployed for one month and trying to save where I can. Otherwise, it cost me right at $100 for a months supply :/
You're welcome.

You can call the insurer directly to see if this is a possibility and if so,is there a number for the doctor to contact directly.
It helps expedite the process.

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Last edited by Phoenix; 11-27-2012 at 09:17 AM. Reason: wording

 
Old 11-27-2012, 09:02 AM   #5
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Re: Question about insurance and what they will pay for as far as my pain meds

You do not want too just double the number of 5mg because that would also double the amount of acetaminophen you take each day. 10s are pretty normal, surprised in is not in their formulary.

 
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Old 11-27-2012, 09:41 AM   #6
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Re: Question about insurance and what they will pay for as far as my pain meds

Pandy,

DaffyDolphin makes a good point.

My pharmacy only carry regular Oxycodone in a 20mg solution or either 5mg or 30mg Immediate Release tablet.
The others are a mixture of the two substances explained by DaffyDolphin.

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Last edited by Phoenix; 11-27-2012 at 10:04 PM.

 
Old 11-27-2012, 05:37 PM   #7
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Re: Question about insurance and what they will pay for as far as my pain meds

From how I understand the question, it is an insurance formulary list issue, not a pharmacy stock issue (since Pandie is able to pay cash). If its Oxycodone (not Percocet), there is no Tylenol. Its likely easier to have your doctor write it to take two of the 5 mg pills then deal with the insurance to cover the 10 mg ones. Although with some phone calls / forms that could be done, its likely that would have to be renewed at certain intervals such that it would be a pain.

I'd just discuss with your doctor that your insurance doesn't cover the 10mg ones so you've had to pay cash at $X per month, and you've discovered the 5mg would be covered. S/he will probably offer to write it that way.

Only issue I could see is that it is then 8 pills a day, which is 240 if you get a 30 day supply. Per my pain doctor, anything over 200 pills gets flagged by the DEA, such that some doctors avoid writing any CII script over 200 pills. Because of that my doctor writes my methadone script in two week increments, where one has a "fill after" date, since otherwise it would be over 200.

If you end up staying on the 10mg and not dealing with the insurance, definitely shop around for the best deal. Its common for the list price of meds to be quite marked up. Sam's Club or Costco is usually the cheapest (you don't need a card to go to the pharmacy), followed by Walmart. Most pharmacies will price match (excluding Sam's & Costco), so you can just call up Walmart or wherever and ask their price for what you take, then when you drop off the script at your pharmacy, ask them to price match that pharmacy you called (they will call and confirm the price).

I'd be cautious of discount cards as some are scams, or at the very least, they get your personal info and will send you junk. The manufacturers of brand name meds often have discount programs (reduced copay for 12 months or similar) and patient assistance programs (free meds if you are low income), but there won't be anything for generic oxycodone. Best wishes.
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Last edited by tortoisegirl; 11-27-2012 at 05:45 PM.

 
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Old 11-28-2012, 07:26 AM   #8
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Re: Question about insurance and what they will pay for as far as my pain meds

I have this exact issue but because I don't have any health insurance so I have to pay cash for all my prescriptions.

My PM worked with me and we have stayed with the OxyIR 5mg (as Kate mentioned...these are Oxycodone WITHOUT any Acetaminophen) and I get 240 of them a month because I take the 8 a day.

The 10mg or higher ones that are usually stocked by Pharmacies are much more expensive so we have just kept it this way to help me save money.

I go to Sam's Club (you do NOT have to be a member to use their Pharmacy) and I pay $53 a month for the 240 of them....

They are generic of course which is no big deal to me as I have never seen any difference between generic/brand over all the years I've been on medications.

As mentioned, it would be good to at least try and see if your Dr. can write a letter to your insurance company requesting that you be on this particular milligram and see if they will cover it...Otherwise, you can call around and see what the prices are in your area for the 5mg...Many times a Pharmacy will match a lower price so always speak with the head Pharmacist.


Good luck.

 
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