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    Old 03-11-2016, 12:22 AM   #1
    Eva 14
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    Angry Insurance Refuses to Pay for ANY Pain Meds?

    Today I received a registered letter from Blue Shield, my health insurance company for decades. I've been with the same pain doctor for seven years and have been on the same meds and dosages for seven years. I am in shock.

    The letter states that a 'medical necessity review' was performed on my prescription claims history. A 'clinical review' was performed on my prescription history. Insurance states that they need 'medical justification' for my allegedly 'high' dosages of medication. Seven years and no problems---now, suddenly this?

    Blue Shield says my doctor needs to 'contact Pharmacy Services to provide treatment plan and medical necessity information, including written documentation of office notes with diagnosis and appropriate clinical evaluation for continued coverage of current and new prescriptions for narcotics and sedative hypnotics'.

    Blue Shield says that if they don't get this info by May 1st, they will not cover ANY more of my prescriptions.

    I don't understand what's going on. I did not do anything wrong. I feel like I'm being discriminated against for being a pain patient. My pain doctor already got a prior authorization for one of my meds years ago, but NOW Blue Shield is claiming that they need 'prior authorization' for ALL of my meds!

    Has anyone ever heard of such a thing? Has this happened to other pain patients? Is this a recent phenomenon?

    My dosages are not that 'high'. My dosages are moderate, and my pain management regimen is rather complex. I wonder if this is motivated by money? My meds are pretty expensive, and maybe insurance is upset about that. But I also pay a fair amount for this insurance.

    The letter is pretty offensive, IMO, in that it reads as if they doubt the 'medical necessity' of my meds, and they seem to think my dosages are too 'high'. They claim to be 'monitoring the safe and effective use of prescription drugs'---like I'm a drug addict who needs to be protected from myself. IF I disagree with the info in the letter, I'm supposed to call the 'Special Investigations Unit". So, I've been 'investigated'?

    'In order to continue coverage, ALL prescriptions for narcotics will require prior authorization'. My doctor needs to 'submit medical necessity information for current and new prescriptions for narcotics and sedative hypnotics'.

    I only get meds from ONE doctor. I've followed all the rules, but still, I get this? I recently filled a medicine at a new pharmacy--I don't know if that triggered this? (I had to get a strong pain med at a grocery store pharmacy, instead of the indy pharmacy that just shut down. I thought the pharmacist looked at me a little bit strangely. She asked several questions about my treatment plan, but I cooperated fully. She called my doctor and verified the script). I try to fill all my meds at one pharmacy, but I've had to go to two different pharmacies for several years. (My main pharmacy cannot get a certain med).

    Both my pain doctor and I are getting pretty frustrated by the attitudes of some pharmacists---they're really cracking down on pain meds. But I didn't realize that insurance could also question a doctor's ENTIRE treatment plan---that seems like practicing medicine without a license. I could understand if insurance had a problem with ONE med being too expensive, but suddenly, they have problems with ALL my meds?

    I don't understand what's going on. My pain doc is retiring, and I'm worried that no new pain doc will want to prescribe for me, now that I've got some sort of 'red flag' from my insurance.

    This letter shows no respect for my pain doctor's knowledge, either. My doctor has been a pain specialist for over 30 years---he knows what he's doing. He's not prescribing these meds for no reason, as my insurance seems to imply.

    My local pharmacy (been around for 30 years) was just shut down due to DEA pressure. I also suspect that my pain doc is retiring early due to pressure. My pain doc says the government is trying to take away opioid pain meds, and I think he's right. In the past couple of years, the pressure and the crack-downs have been pretty extreme. (None of this has made the local paper, but the info can be found online).

    Has anyone ever gotten this sort of letter from their health insurer? How worried should I be? I did nothing wrong, but I still feel like I'm being treated like a drug addict. My insurance refusing to pay for ANY pain meds unless they get 'documentation'? Have I been 'red flagged', even though I haven't done anything wrong? Insurance doesn't understand my pain or my med regimen; it really irks me that these people are standing in judgment of me.

    Thanks for any advice.

     
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    Old 03-11-2016, 07:33 AM   #2
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    There are certain combinations of meds, opiates and sleep aids, opiates and benzo products, which typically are involved most often in cases of accidental overdoses and deaths, and insurance carriers , along with pharmacists are being ever more watchful of these combinations of meds being supplied to a patient.
    It sounds simple enough, have your doctor provide the requested documentation and treatment history, and that should resolve the problem.

     
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    Old 03-11-2016, 07:48 AM   #3
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    I wouldn't be worried. Just do what they ask. This is just insurance companies being insurance companies and trying not to insure the insured. FWIW after 45 years on my husband's health plan, we were recently asked to show proof that we are indeed married. That's after 45 years of insurance claims and 2 kids. Sheesh!

     
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    Old 03-11-2016, 01:24 PM   #4
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    I agree. I doubt its anything personal. They likely were auditing for certain med combos (most pain docs won't do opioid + benzo as it increases risks), dosages (you and your doctor may think its average but they may think its high), and/or yearly costs, and asking for verification the meds are medically neccessary.

    They have the right to deny anything off label, medically inappropriate, etc. They have an entire department which scoures literature and makes policies on what they will cover and in what circumstances. Your doctor can provide the info and even appeal if it comes to it, but the insurance doctors make the decisions. I don't agree with the ststem either, but its the way it is.

    Often its arbitrary too...I take two courses a year of a $1,200+ obscure off label med and they approve it no problem. But they won't pay for $100/month for Ritalin as I take it for hypersomnolence, not ADD. The Ritalin probably gets flagged as its on their radar as its more common and more likely to be abused. My insurance also requires my pharmacy to ask how often I get migraines each time I fill my Imitrex...maybe to check that meshes with how often I fill it? My pharmacy couldn't put it on auto fill either. Although often its about money, thats not always the case. Liability is another variable.

    Work with your doctor to get them what they requested. Its unlikely they will stop paying for all pain meds. However, they may set a certain daily dose limit, say they will pay for certain meds but not others, or require you to try certain meds before they will pay for others. Its also likely that since you got put on this path, they will require documentation on a regular basis, such as yearly. I hope this gets resolved quickly. Best wishes.

     
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    Old 03-11-2016, 05:23 PM   #5
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    Thanks for the replies, everyone. I did a little bit of online research, and--sure enough--Blue Cross Blue Shield recently instituted a program designed to limit the amounts of pain medications that patients can receive. News sources say it's the strictest opioid policy of any private insurer. So that explains why all of this is suddenly happening NOW. Am I allowed to post a link to an article?

    Blue Cross Blue Shield is demanding prior authorization for ALL opioids prescribed for longer than 30 days! It's pretty ridiculous, IMO. They will likely continue to demand repeated documentation from doctors of chronic pain patients, and the doctors will have to keep 'justifying' their prescribing practices. (Think of all the time that this wastes for hard-working doctors).

    There's also a great article in which a pain management specialist criticizes the policy as overly onerous and restrictive. As if doctors are not already under enough pressure from the DEA and other government agencies, now doctors have additional red tape and hoops to jump through every time they decide to prescribe opioids to a chronic pain patient. (Doctors are not going to want to treat CP patients any more--too much hassle).

    Chronic pain patients are NOT exempt from this policy. The only patients who are exempt from the policy are the terminally ill with cancer.

    Of course chronic pain patients need opiates for longer than 30 days! Requiring doctors to submit additional paperwork and documentation every single time they write a script for a pain patient is a terribly misguided policy. BCBS is proudly proclaiming that through this new program, they've greatly reduced the number of opioid prescriptions that are being written. That just tells me that they've increased the number of CP patients out there suffering.

    Doctors don't want to prescribe opioids. Pharmacies don't want to order, stock, or dispense opioids. And now health insurers don't want to pay for opioids. The government's crackdown on prescription pain meds is almost making pain meds illegal. Technically, pain meds are still legal, but if something is almost completely inaccessible, it might as well be illegal.

    It's so hypocritical the way that BSBC claims that they are NOT taking opioids away from legitimate chronic pain patients. In today's overly-restrictive climate, I find it very hard to believe that addicts are getting meds from pain doctors, or that pain doctors are handing out pain meds like candy.

    These are bleak times for chronic pain patients. I remember watching the Congressional hearings about Oxycontin way back in 2003. I had hoped that once all of the states instituted Prescription Monitoring Programs to catch 'doctor shoppers', all of this Drug War hysteria over LEGAL drugs would die down. Some chronic pain patients testified about the beneficial effects of opioids, but most of the politicians didn't care about that. I remember this one senator proudly telling a CP patient, "We CAN indeed take away your medicine". That's exactly what's happening now!

    The pendulum really needs to swing back towards liberalization of pain meds, otherwise CP patients will be left with very few options left to lead anything near normal lives. The regulations are getting way too stringent.

     
    Old 03-11-2016, 06:12 PM   #6
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    This is unfortunately nothing new. Plenty of insurers are requiring this for many classes of meds (same with having "step" programs, etc). I read that this started for some BCBS plans in MA in 2012. Some doctors actually refuse to do prior authorizations and the like (as they only get paid when they see a patient), so their patient needs to choose between paying cash, asking for a different med, or finding a new doctor. Note that this isn't likely all BCBS, as there are many subsets and plans (plus I have them and just filled my pain meds last week without issue).

    One person that has a BCBS plan may be subjected to different policies than another with a different BCBS plan. It can also depend on the employer sponsoring it or whatever...some plans are more restrictive to keep costs down. I really hate the way the climate is shifting, but there is only so much we can do about it. Unfortunately I think things are going to get worse. Much of the data is against us as far as the effectiveness of using opioids for chronic pain. Hopefully your doctor is willing to do the paperwork and it goes in your favor. Best wishes.
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    Old 03-17-2016, 10:02 AM   #7
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    I recently had my prescription for Lyrica denied also. I had been taking it for a year and a half. It worked very well for me. They suggested I try the gabapentin to see if it was as effective. I just started it about a week ago. It has helped with with the nerve pain and I have not had any side effects. Hopefully it will hold for me. I was pretty upset about the denial... I thought if my doctor would have wanted me to be on the gabapentin, that's what he would have prescribed to begin with!

     
    Old 03-17-2016, 01:12 PM   #8
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    I have a medicare advantage plan(Humana PPO)due to having SSDI; I have had them since I went on SSDI in 2010-I have tried probably most of the long acting meds available-when I went to fent patches, I started with the generics; and none of them worked for me to my dismay.

    Then my doc insisted I try the brand name Duragesic; and to my surprise; they were very effective and I finally started to get some good relief-but my insurance(Humana PPO)of course did not want to pay for them ($2,000)for 15 patches-they said I must try(step)others first!! What is funny is that I ALREADY HAD!! They are the ones who paid for them, so ahh.......

    MY doc wrote a letter to the auth dept to that effect; they finally approved them.

    This is a clear case of the rt hand not knowing what the lt hand is doing, as they already had documentation of this in THIER files; they had paid for all the other generic patches as well as the other long acting medications they were saying I must try first, lol.

    Dealing with the PEOPLE at the insurance co. can be a real obstacle in trying to get what we need, indeed.

    I was thinking of changing to BCBS of Al this past open enrollment, but I was to afraid of having a problem in continuing getting the Duragesic patches.

    I was also rx'd Nuvigil for hypersomnolence; I need prior auth, which was approved, for 30 tablets $555.00;(no generic available) which I find OUTRAGEOUS, plus they were useless/ineffective-how do the pharmaceutical co.'s get away with these outrageous prices!!

    My doc is having me try Provigil instead which also required prior auth $166 for 30 (generic)tablets. They seem to help a little, but not enough to solve the problem; but I just started taking them.

    There just seems to be no rhyme or reason with how some of these insurances work!!
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    Last edited by BB07; 03-17-2016 at 01:30 PM.

     
    Old 03-17-2016, 08:08 PM   #9
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    Ask your doctor for help.

     
    Old 04-11-2016, 07:37 PM   #10
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    Judging by all the press I am seeing from every news agency on the planet I think this problem is going to get much worse in the future. The statement I read saying that the only people who will be allowed opioid medications will be cancer patients is not an unusual statement. I have heard that very same thing said recently on at least 3 other occasions. If you are in need of pain relief and you DON"T have cancer I suggest starting right now finding some other alternative. I feel our days are numbered and I for one am absolutely NOT looking forward to it. Laying in bed 24/7 in constant pain isn't my idea of joyous retirement.

     
    Old 04-12-2016, 05:09 AM   #11
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    I've definitely prepared since the start for the possibility that at any time my pain meds could be cut off, and best case scenario you get a month to taper down or find a new doctor. In my area of WA its pretty bad and most pain docs are anti daily opioids for chronic pain, even for pain patients with documented severe pain and years of failed treatments who do well on them. My clinic is the only place I could find a few years back which had a true treatment plan and I felt confident in them actually wanting to improve my pain levels and quality of life (and they have). I fear for the future, but all we can do is prepare. Best wishes.
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    Old 04-22-2016, 02:11 PM   #12
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    How do we "prepare???"
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    Old 04-22-2016, 07:43 PM   #13
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    Re: Insurance Refuses to Pay for ANY Pain Meds?

    I have some work vacation days saved, cash saved, a backup plan (including a neurologist and primary doctor who may be willing to prescribe at least short term), and some extra meds saved. I would never do anything which would put me in danger of failing a UA though.

    Its rather "easy" to save short acting meds as if the prescription is as needed, it doesn't need to be in our system with a UA (although I imagine if it never showed up on any test it would be a red flag). I also tend to self-limit as if I take them often they don't work as well. Breakthrough meds really aren't meant to be taken on any sort of schedule anyways. I think doctors who tell us to take them X times a day or suggest to take them in between doses of long acting meds which don't last long enough (when they should swap the schedule to be more frequent) really do us a disservice vs. those who say to take as needed and only give small quantities.

    I only get one dose a day, so many days I take none, some days I take one dose, and sometimes I take two or three doses. I even have some long acting meds saved as every once in awhile I forget to take a dose on the weekend, I've been on Methadone for probably 6 years now, and a previous doctor did 30 instead of 28 day scripts so sometimes I had to fill early due to a weekend. Best wishes.
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    Last edited by Administrator; 06-16-2016 at 07:48 PM.

     
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