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Appealing Insurance Denial for Hydrocodone

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Old 08-04-2017, 04:54 AM   #1
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Appealing Insurance Denial for Hydrocodone

Hi fellow pain sufferers,
It's been a while since I've posted, and I'm usually over on the back boards. But my problem right now isn't my actual back problem, it's my insurance company. I suspect more and more of us are going to be dealing with my current problem as the crackdown on opioid use tightens.

Here's my problem:
I've been on hydrocodone since 2006. My issues are back related. I won't go into all of that. Suffice it to say that all of my doctors agree that long-term hydrocodone is appropriate for me and that there is no better alternative. I've been being prescribed 100 tablets/month, and that's worked out pretty well. My insurance company has decided that I now should receive 42 tablets at a time and can get only two prescriptions per month. That means that I will run out of pain meds before the end of each month, plus I have to make that awful hour and a half drive to pick up the written prescription twice a month instead of just once.

I am working on writing my appeal letter to the insurance company. Is anyone else dealing with this? From what I've read online, the bottom line in writing an appeal is, well, the bottom line, meaning money. If I can show the insurance company that it will cost them less to let me have my former prescription (100 tablets at a time once a month), it should fly on through. I'm pretty sure I can't show it will save them money, so I need to figure out what WILL have a positive impact for the reviewer. My doctor has already intervened and gotten them to let me have two weeks at a time instead of the one week they originally stated. I'm sure he will continue to help me however he can, and I'll send him a copy of my appeal letter, but he's done what he can for now. Any suggestions on what to include with my appeal letter? I'm going to be one hurting wet noodle if I have to run out of pain meds every month! I already am never pain-free.

I went in and talked to my pharmacist about the source of these new regulations. She told me that currently, it's my insurance company, and many other insurance companies are doing the same thing. But she expects that similar rules will soon be passed at the state level, and that soon after that, similar rules will be passed federally, at which point everyone using opioids for chronic pain will be affected.

As if the pain itself isn't enough to deal with...

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Old 08-06-2017, 09:01 PM   #2
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Re: Appealing Insurance Denial for Hydrocodone

Sorry you are dealing with this. Double check the cash price of paying for the remainder out of may be quite reasonable, especially if you shop around (some pharmacies cost double of others) or use a discount coupon (there is a popular website where it is common to be able to save 2/3 or more on the cash price of a med that I have used when my insurance won't cover stuff off label, like stimulants for idiopathic hypersomnia instead of ADD). I'm guessing your insurance says it is only to be used for acute, not chronic pain, due to the new "studies" that have shown opioids are ineffective for chronic pain? Often they aren't going after the expensive meds, but the meds they get the most claims for. ie. I got coverage multiple times for a rare $1,000 med to be used off label, but they won't cover my common $50 med! Definitely appeal to the highest levels you can though. Best wishes.
constant headache since 2006

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Old 09-01-2017, 03:53 PM   #3
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Re: Appealing Insurance Denial for Hydrocodone

Hi!! ***hug***

-I am in pain management too. I am prescribed 120 per month, but my PM doc just told me that by 2018 they have to drop me down to the CDC's recommended level - which is about 25 pills less. Didn't you have MULTIPLE fusions - all the way down your back?

I have had to adopt multiple options to opioids - the best being water aerobics. When I first started 5 years ago I could barely make it for 30 minutes and certainly wan't jumping around!! Now I can do 3-4 classes a week, most of them 60-90 minutes. It really helps me stay flexible. You feel weightless.
I haven't had to petition my insurance company yet, I hope I never do! I really hope you have success with it.
07/2006: A/P fusion L4-S1; DX DDD
09/2009: started PM
04/2011: Right rotator cuff tear
09/2011: re-tore shoulder in PT- lost 30% function in shoulder
06/2013: diagnosed with failure of L2-L3-L4

Last edited by Administrator; 09-01-2017 at 04:15 PM.

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