MED D ins controlling meds refusing to fill

Have taken Fentanyl patch 100mcg change every 48 hrs. Oxycodone 10 mg 120 tabs monthly prn. Went to fill my meds. on 01-02-17, at Wmart the three boxes of patches was $268 and they wer $5 co pay last year all year. Wmart was out of oxycodone till Thurs, Went in on Thurs *(was told would be ready) 01-05-17) and was told insurance refused to fill them. I asked why "did not know , just was happening with many people who had more than one med for pain. " Called the ins. co and was told it exceeded the new med dosage adopted by medicare and medicaid as of 01-01-17. I asked what was med dose, she did not know. Spent hour on phone no further, and then went back to pharmacy and was told it just needed drs. authorization. SO I came back the next day, WM didn't know anything, they didn t contact dr. I said the dr wrote the scripts just like they had filled for past years, so why did he need to authorize. DID NOT KNOW had to call ins. co. Called DR ofc, knew nothing about it, called ins. co, still no help, said it exceeded med dose. NO explanation of what med dose was. I googled and found it meant MORPHINE EQUIVALENCY Dosage. Which is not to exceed 400 mg a day from all sources of pain meds. The equvilancy chart says that my prn oxycodone, is now the same as scheduled as they divide number of pills by 30 days, and then multiply that dose so 4 pills at 1.5 conversion is 60 mg a day. The fentanyl converts to 240 mg a day with a 100 mcg match, but becasue I get 3 boxes they were increasing the dose I was actually receiving by adding on extra. I went through over 10 hours of talking to the pharmacy division of the insurance company and finally I figured it out for them. I told them I change the patch at 48 hours due to skin breakdown, and I put on a new patch, so I m only getting 100mcg hourly not combing the patches, . Medicare converts 25 mcg hourly to 60 mg daily so mine is 4 times that and equals 240 mg daily and the other med is prn but that doesn't matter to them. I told them it is not scheduled I might not take any , that you cannot do the equivalent dosage for prn meds, EVERYTHING might as well be scheduled as that is how it is converted. So they kept on and on and finally I asked why I need a dr to write scripts since they are the ones who get to decide my meds, and dosage. In the end I got a pharmacist to whom I explained the dosage did not increase as I changed patches not combined. My dr ofc did not help at all so I wrote down a whole explanation of me being a compliant patient for years you used my med to try to get some normalcy in my life when I lived with the kinds of pain I had and how long. I did not dr. shop I did not us multiple pharmacies, etc. THEN explained how the dosage converted. THE next day I got a letter approving the oxycodone, but a letter denying my patches as they are no longer on formulary. I contacted medicare to change part d, and am still waiting, I also had to pay $50 for the oxycodone, I paid $10 monthly last year now over $300 monthly.. I can't afford that, nor is it necessary. The only er med is ms contin on their formulary. DOes not help me does nothing but make me itch. SO I m in for a battle. I also don't get the Medicare and Medicaid control thing as the ONLY people where I live that can get any amount the dr. prescribes and the name brand meds are the people on medicad and they pay 60 cents a script. THIS HAS TO END> IT is ridiculous, we have to have med insurance, and then they, not my dr, gets to decide what med and how much. WHY

The CDC Guidelines recommend Opiates for Chronic Pain are not to exceed 90 mg Morphine/90 Morphine Equivalent Daily when prescribed by a doctor that is not a Pain Management Doctor. But. many Pain Management Doctors are following the 90 mg Daily Dose also.

Medicare Prescription Part D Plans can limit meds if they want to. You can appeal the denial. But don't plan on winning. How old are you ? Your age may also play a role if you are 60+.

Post Edited (Mercy&Grace) : 1/22/2017 9:12:23 PM (GMT-7)

The dose is not high, as it is just one patch and 10 mg oxycodone for breakthrough. I had nursing home patients wearing 2 or 3 patches at a time taking MS Contin 90 mg up to 180 mg three times a day, and then MSIR or oxycodone as breakthrough. My dose has been the same for about 3 or 4 years. I did find what is called the Morphine equivalent dose chart. It was in 2012, when medicare and medicaid started looking at over utilization of opiates. IT was a letter that was to be sent to the prescribing dr. stating that there was a concern by the pharmacist of ins. co that the patient could benefit from counseling and so forth regarding opiate use. The doctor had 3 choice to reply. 1. He looked at the patient and the dosage and had no concern2. He looked and thought there could be reason to think about it. 3. HE also was concerned and thought the patient could benefit from the counseling. It also was to go out to any patient that was using more than one doctor and4 pharmacies to get their meds. NONE of which do I fit the picture. There was alot of work done to come up with the theory that it was much more effective, and actually used less meds, when the patient utilized an extended release med and then had a breakthrough prn med. NOW it does not matter if it is prn of scheduled as they all get figured into the morphine equivalency dosage as if they are scheduled. CIgna is a bad company, but you can google Medicare Morphine equivalency dosage and get the info.

Purplereading:
My understanding is that the restriction of opiate/narcotic prescription dosing now in effect (commencing Jan-2017) has origins in the policy writing of the "National Pain Strategy" that was issued in joint collaboration by the DEA, NIH, and CDC in March-2016


The National Pain Strategy is a policy statement that limits prescription narcotics/opiates for pain of non-cancer to a pre-determined morphine equivalency dosage. I thought the morphine equivalency value was 120 mg morphine - but I may be mistaken. Perhaps someone can verify the morphine equivalency value so that we can all be on the same page.

Any single prescription or prescription combinations written to an individual falls under scrutiny of the morphine equivalency dosage level.

Your physician has no vote or say in the manner to dose you with narcotics/opiates at a higher level except on appeal of the denial.

You should be provided with a denial letter that outlines why/how your prescription(s) were denied and the appeal process.

I am on clinically designated palliative care (care and comfort services). Palliative care distinction implies that one has a serious, life-threatening chronic health for which there is no cure or convenient "fix." I have a laundry list of co-morbidities. My life is no picnic.

That said, even I must jump through several hoops for narcotic dosing that is clearly above the morphine equivalent dosing level. My narcotic cocktail consists of Fentanyl 75 mcg every 48 hours and dilaudid/hydromorphone 8 mg 6 x a day. It is a hefty dose, enough for a small herd of zebras. This dosing keeps me from going mentally insane from bombardment of pain signals due to advanced avascular necrosis and keeps me standing/walking for short distances.

I am a former marathon runner and physical therapist. Running was my personal oxygen. Now I barter with God/Higher Power to just enable me to walk outside to a park across the street.

But make no mistake, I understand and empathize with your plight in what has become an Ordwellian ordeal for individuals whose misfortune is that they are shackled by inescapable, chronic pain.

Even on Palliative Care, my narcotic cocktail is reviewed by three separate panels (I reside in Oregon): 1. State commissioned narcotic oversight committee; 2. The Pharmacy Review Committee established by my medical insurance provider; 3. Prescription must be supported in rationale by at least one additional independent licensed pain management physician.

My prescriptions have generally be approved, but not always. I have had to appeal on one prior occasions. My prescriptions have been authorized in 3 month increments, the entire process starting over every 3 months. I received good news this month that my narcotic cocktail has been approved for 12 months, Jan-17 to Jan-18. That is virtually unheard
of.

I offer my personal story to provide illustration that we all are struggling with the new opiate prescribing climate.

I do not foresee the situation improving.

Between the likely repeal of the Affordable Care Act and increasingly restrictive access to prescription opiates, there is little to celebrate if you are a person with serious, ongoing health conditions. I find it difficult to keep finding the inner strength to continue to plug along.

I have used a pictorial functional assessment provided by the American Pain Society in presenting my case of pain and its downstream effects on me, as a person, in communicating with the narcotic review committees that review my prescription dosages. I also include a one-page, bullet-pointed summary of how pain impacts my ability to engage in life. I have both to be helpful in supporting my claims for the prescription cocktail that I take. I have even provided one pictorial functional assessment without medication and one pictorial functional assessment with medication, so that the review committees could "see" the benefit that my prescriptions enable me. Ex. Without medication walking 10' is a difficulty 8; with medication walking 10' is a difficulty 4. The pain assessment using small drawings that illustrate varied abilities and frailties for several daily activities (walking, climbing a flight of stairs, showering, preparing a light meal, employment, hobbies, general ability to enjoy life).

I have found the American Pain Society pictorial functional assessment to be a powerful tool in my arsenal of communication. Feel free to log onto the American Pain Society web-site to see and download the pain assessment.

I do not know what the future will hold for those of us demoralized by unrelenting pain. I do not foresee that the overall scheme of access to prescription narcotics will improve or ease.

I do work diligently on incorporating alternative ways and means to lower my pain threshold. Use of warm buckwheat packs; use of mediation and relaxation technique; diversion techniques - crossword puzzles and jig saw puzzles, the reading of books to take my mind to new places, watching NetFlix DVD; the companionship of a pet/dog, loving cuddles; getting outside to be with nature, going to neighborhood parks. I encourage everyone with chronic pain to find alternative means of adapting and adjusting and coping.

Pain is pain. And there is an upper limit to what one can tolerate on an ongoing basis.

I will not lie. If for some reason my narcotic prescriptions were drastically reduced or taken away, I would consider the unspeakable act of suicide. I have been worn down to figurative smoldering embers by years of unmanaged pain.

Use this forum as a safe harbor where you can find support and commonality of others who experience pain. Use this forum to find a way of expressing your frustrations and anger, so that you can way of living your best life within the constraints of what ails you.

Know that the members here care, about you,
- Karen -

When someone is suffering, how can we ask them to suffer more.

Purple:
The restrictive environment of prescription monitoring and oversight of narcotics/opiates is here to stay . . . and I suspect may be subject to more control, not less, over time.

As a country, we are witnessing tectonic shifts in the underpinnings of politics and policy that shape our every-day lives. No one is immune from feeling its effects. As individuals with chronic pain, we have not been singled out for attack and disruption. We are among million of people who are feeling the effects of deep and profound change.

I am of the opinion that the United States, as we have come to known her and love her, is forever gone. There is no turning back the clock to the beau colic "Leave it to Beaver" utopia of the 1950s.

Pendulum movement swings to the left and then to the right, a metronome.

My hope is that the current direction of the pendulum toward increasing restrictive narcotic policies will, over time, find way to move in direction toward the easing of restriction. I can only hope. I have to keep this hope alive in order to not give up on life myself.

Certainly, you have the right to appeal the denial through Cigna. If that gives you a measure of control to express your dispeasure . . then file an appeal. It was a cathartic exercise for me when I did appeal to my medical insurance provider; just writing the appeal was a helpful exercise in expressing my deep frustration.

For anyone who is facing a reduction in dosing, I encourage you to explore an emerging area of care called "functional medicine." A functional medicine practitioner is a physician who has specialized training/education in rehabilitation medicine and interventional radiology. They are frequently at the cornerstone of professional sports teams - their task is to keep athletes in top physical, physiological, and nutritional balance. Functional medicine is now expanding to the general populace, focusing on preventative well-ness and functional restoration from injury or illness. Functional medicine is whole person medicine and it is smart medicine.
Explore whether functional medicine physicians are in your community.

I also use Arnica Montana, a homeopathic agent for muscle and joint pain. It is available as tiny pellets that you take orally in pre-measured vials that you purchase (Whole Foods, Pharmaca, Amazon, or other natural-organic based food/pharmacy store). I find Arnica Montana helpful. Genuinely helpful.
- Karen -

I made an appt to discuss with my dr. HE said he will probably no longer take any new pain med pts. ALTHOUGH while he was in school, he, like me\ and other RNs , were taught that pain is the 5 th vital sign, and we should treat it and that it is what the patient says it is. He went on to try to figure out a way to not reduce the total dose, but use different dosing. IN the end, I wrote a letter, stating I was a 63 year old chronic pain patient who used the meds to get a somewhere normal chance at life, had used them for years, never abused them, and did not ask for early refills, etc. The real reason that Cigna was denying was that they were adding my extra box of patches, ( as I change every 48 hours instead of 72 hours, ) in as an additional dose on top of the what I am actually getting. I explained to them that I change every 48 hours, but it does not increase my dose I am still only getting `100 mcg an hour, I just use more patches and they are discarded, when a new one is applied. Per their chart the 100 mcg is 240 conversion and the oxycodone is PRN and they were adding it as a scheduled dose 4 times a day. The oxy also converts as 10 mg being 15 mg to MS . IN the end after I submitted this letter I did get an acceptance letter that they would fill my two narcotic meds as I had taken them for the past 2 year from Jan 17 to Jan 18 BUT Medicare came through and got me a different part d. The unfortunate is that I paid over $400 the first month due to Cignas confusion, and now I have to make a $400 payment of deductible with the new policy. We will see where it goes. The pharmacist also said he can do hard and soft overrides. So my meds are approved till 18. Next year I will have to hunt again.

I'm having the same trouble with Anthem, an extremely disorganized, rude company that (when I can reach them after the usual 30 to 40 minute wait on hold with the same ditty played in a loop) is never able to give me the information I need. At one moment it might be that my Fentanyl is not medically necessary, or in the next that I need a blood test proving that I take the darned stuff. I am angry that they waited to tell me that they require the blood test just as my prescription is up for renewal, so I have the choice of paying out of pocket, not really affordable for me, or going through withdrawal and severe, immobilizing neuropathic pain. When I applied, I told them about the narcotics. Now they are backing out. I think it is bait and switch, and I am angry and scared. Without the narcotics, the pain, a result of chemotherapy gone wrong, is too severe to manage a normal life, so to be told it is medically unnecessary is enraging. They are not saying they will pay for the drug even after they have the blood results.