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What insurance covers Actiq?

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Posted 10/22/2013 9:16 PM (GMT 0)
I know some of you have posted that you bought private health insurance that actually covered Actiq for off-label uses.

I am trying to sign up for a health plan. In an ideal world, I would get one that covered my prescriptions. If not, it's disadvantageous for me to even have prescription insurance. You can email me to my HW email by clicking on my name to the left, if you prefer. If you do that, please let me know that you PMed me. Otherwise, I'm sure others would love to get ideas, too. I've tried searching through old posts, but haven't found anything from the last couple of years that actually names a private insurer (if you get coverage through work, that won't help me -- I'm looking for people who bought insurance for themselves either from online or an insurance broker).

Thank you!!!!!
Posted 10/22/2013 11:51 PM (GMT 0)
You might try Tina(Blessedx8) as she has the flu she's not been on much the last few days. She would be most likely to help with this question.

Others may have some experience with other off label meds and insurance. Hopefully someone will have an idea, I know that I took out Humana as my Medicare Advantage plan and it will cover it as a certain tier and that particular tiers not a set amount rather its a percentage of cost, my parts 30% but that's probably a whole lot better then without that.

Good luck
Posted 10/23/2013 12:07 AM (GMT 0)
It seems that this is one drug that many of the insurance companys are not approving. It is so costly even with insurance.

I am thinking Tina is the only one at our forum that is using this for her migraines. She has been popping in & out even though she is sick right now.l

Susie
Posted 10/26/2013 5:34 AM (GMT 0)
Thanks Susie & Vickie.
Yes, 30% co-insurance is wonderful. I'd take that any day. With my current coupon for a local grocery chain, I save 40% (pay 60%), but that grocery chain is closing down at the end of the year & then I will really be up the creek because next closest price is about 25% savings (pay 75% of cost). I think I qualify for Medicare through a special program in my state for low-income people with disabilities so I will maybe look into that some more. I thought that Medicare always denied Actiq for those without cancer, so that was good information. Thanks!!!

If anyone else has any other experience, I'd love to hear. :D
Posted 10/26/2013 1:04 PM (GMT 0)
There are different medicare part d's that do approve the actiq. I believe there may even be a generic available for it now. I know it is listed in my formulary and I have an RX program that is only for Ohio residents.

Any chance you are in Ohio?

Trudy
Posted 10/26/2013 11:49 PM (GMT 0)
I just now that of something, Tina lives in Ca. and with private insurance coverage varies from state to state. Everything hinges on the language in the policy. What I would do is an internet search for your state to see if you can pull anything up. What her policy may cover in Ca. could be totally different than where you live, so its really pointless looking for that info on an out of state person.

I hope you find something. I think it will be difficult, this is a drug insurance companys do not like to pay for. Seems to me Tina's dr had to do an appeal to get hers covered.

Good luck.......Susie
Posted 10/27/2013 4:09 AM (GMT 0)
does comp pay for actiq?
Posted 10/29/2013 3:27 AM (GMT 0)
Thanks all. I do know that it varies from state to state, but I am hitting a brick wall & was hoping to at least have some starting points. I will look into the options that people have suggested.

Luie, Workman's Comp is a state-run program. It depends on which state you are in. I can tell you that the WC program in my state is gutted & they don't cover it, but you'd have to check with the program in your own state. Good luck!
Posted 11/2/2013 2:46 AM (GMT 0)
ok, I have a new related question. I've been striking out with insurance so far. I don't qualify for Medicare for another 15 months, so I can't go that route.

I spoke with a rep at my state Medicaid office about generic Actiq. He gave me the standard line about that it can sometimes be covered if you submit:
1) Letter of Medical Necessity
2) Reason why Preferred Drug alternatives are not an option
3) Evidence that I am on a long-acting opioid
4) Copies of peer-reviewed medical journal articles for off-label uses of Actiq

I'm just nervous because I've been through that craziness with my prior group insurance to no avail. I am scared. I have tried everything else. I am worried I may end up having to cave in and re-activate my application to state-run nursing care. It is the last place in the world I want to end up, but I'm just not sure what else to do.

I've looked into the "obamacare" options through my state insurance exchange & guess what?!! They actually have a clause in them that they will never pay for anyone to get any sort of treatment related to "back pain". I've shown it to a number of people in my community & they all just keep asking the same thing: can they do that?!!!! Of course they can. Stupid lawmakers should have seen it coming. You make insurers cover people & they're gonna find a way to keep earning obscene profits by making across-the-board cuts to coverage. I shouldn't complain too much because my 401(K) is going through the roof, but with over 30 years before I can draw on it, it just makes me irritated that for now I'm stuck not being able to even buy insurance that covers the one medication that actually gives me a chance to live independently. Ugh. Sorry for the rant. Just really frustrated.

My PM is reluctant to spend the time it will take to even apply for Medicaid to cover me for generic Actiq. If there is even a single one of you that got it to be covered anywhere with Medicaid, I know it would go a long way to convince him to give it a try & have his staff put forth the effort required to apply for me.

Thanks!
Posted 11/2/2013 5:26 PM (GMT 0)
A lot of states now will not pay for treatment of chronic pain if they are on Medicaid, no coverage at all. You must be in one of the states that Medicaid pays for treatment of chronic pain. Nothing surprises me any more....Susie
Posted 11/2/2013 11:40 PM (GMT 0)
Hey Frances,

This is another thread I wanted to comment on..... sorry it took me so long.

I've only been successful to get Actiq (or, rather, it's generic).... covered under Health Net and Aetna. No matter what loops I jumped through - I couldn't get it covered under Blue Cross. All that said - I live in California.

I'm not trying to be discouraging, just realistic - with hard as it to get it covered with insurance, I'd be really surprised if Medicaid would fund it. I really would.

How many are you needing a day? I'm down to one a day (give or take; some days none, some days three, but it works out to avg. one per day). This was down from 3 a day.

At Walgreen's, it ends up being about $30/per sucker (if you had to pay outright).

Anyway - I'll keep up on this thread now, if you have any other specific questions - please let me know. Having been on this med for many years now, I've just about seen it all.....

Take care, Tina
Posted 11/3/2013 12:55 AM (GMT 0)
Aetna in my state only covers it for people with end-stage cancer. If you're not expected to die in the next 4 months, they don't cover it here. I also tried BSBS, Humana, UHC, Physicians' Mutual, and so on. I too had jumped through all the hoops with BSBS when I was in a group HMO, but they just never ever cover IR fentanyl for off-label uses.

I'm at 5/day, but am working my way down to 4, and then hopefully lower than that. I was at 4/day pre-op. The pain of the surgery on top of my regular pain, had me at 6/day. Last time I had the SCS surgery I also had to go up on my pain meds for about 4-5 months and then went down quite a bit, by more than 2/3rds.

I've gotten a discount card at Safeway that gives me about $12.50/dose for the 400mcg dose, so about 50% off full retail. Walgreen's will no longer accept any discount cards, near as I can tell, and they dropped OTFC from their own discount program -- though it only saved about $60/box even when it was covered, so no huge loss with that. Disappointed that I can't get the savings there I used to get -- more than 60% off. I'd love to be able to take only 1/day. My goal is to get down to the 200mcg dose at 4x/day. Ideally, I'd really be excited to get to where I only needed it 2-3x/day, but my PM says that might not be too realistic. We'll see. For now, I'm just trying to deal with the pain from this awful incision wound that's infected or something. Once that heals & closes, I can start working out in a therapy pool and that should help.

Man! I just want to be better already! Thanks for all the advice. :)
Posted 11/3/2013 1:16 AM (GMT 0)
Frances,

Do you mind me asking what the Safeway card (discount card) is? I like to have all of these options.... w/ all the health care changes -- and the oral fentanyl being pretty much the only med that helps w/ my migraines -- I like to be on top of this.

Is it a card through Safeway or somewhere else? Thanks :)

--Tina
Posted 11/3/2013 7:18 AM (GMT 0)
I have United Health Care thru Medicare. I am in Texas

I do not have cancer and have never had an issue with my insurance paying for my Fentora (same as Actiq more expensive). They just wanted to know from my PM doctor why I needed it which was really easy. For the past couple months I have also been on Actiq for when the Fentora leaves blisters in my mouth and burns. I will rotate to the Actiq.

I know tons of people on both these meds who do not have cancer. Most insurances are willing to pay for it if your doctor is willing to do his part.

Every January 1st tho they cut me off and I have to get pre approved for it again. We have to go thru the whole same process every year about why I need it and what all I have tried. I get nervous every year and that time is coming up once again.
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