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 Post subject: Not medically necessary
PostPosted: Sat Nov 02, 2013 6:19 am 
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I was on Oxycontin for about 5 years, because of chronic pain from fibromyalgia and Ehler's Danlos Syndrome (hypermobile joints due to genetic issues with how collagen is formed). For the last 2 years I've worked with my doctor to wean off of older meds that weren't helping much anymore, and using some newer meds to streamline treating underlying issues. Went off a muscle replacer, a tricyclic antidepressant I was using to help me sleep, and finally the benzodiazepines I had used for years that were also for improving quality of sleep. After all of that, I was still feeling sedated in the afternoons, and didn't want to be on Oxycontin for much longer because of the possibility of damage to my liver and kidneys, and decided it was time to detox. I detoxed for 3 days in April and then started on Suboxone for pain management and to block the side effects of weaning from the Oxycontin. The last my prescribing doctor said about it was that I may have to stay on it for a few years and then see what my pain baseline is.

Now this week I called in my refill, and was stymied by paperwork because the "prior authorization" for the insurance company to cover the monthly cost of the medication needed to be updated. My doctors office sent in the paperwork, and after a few days it was denied because I am not enrolled in a 12 step treatment program. I called the insurance company to clear up any questions they have, and explained that I had been physically dependent on Oxycontin and using the Suboxone to tolerate the side effects, and have never been an addict and am in a program with my doctors to manage my condition, but that I have no reason to be in a 12 step program as I've never taken the medication other than as prescribed.

The insurance company called my doctor and went over the initial approval for coverage of the Suboxone, and forms were not filled out correctly. The insurance representative didn't know why it had gotten approved in the first place, and informed me that I can pay out of pocket or go without.

So now I'm up a creek without a paddle, have an appointment tomorrow with a pain management doctor in the same office to talk about my "alternatives", but right now I am really angry and frustrated as I feel that I am about to be thrown into withdrawal again, only this time it's completely unplanned and unprepared for, and all because my insurance company has decided that anyone using Suboxone must be an addict, and must be enrolled in a 12 step program or rehab in order for them to cover paying for it.

I am disabled and live on Social Security disability income. Paying out of pocket would take up 25% of my monthly check, so that is not a possibility. Anyone have a similar experience? Any advice?

Right now I think I'm going to get enough for the weekend, then call the insurance company on Monday to beg them to give me a 2 months supply so I can do a proper weaning schedule at the very least.


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PostPosted: Sat Nov 02, 2013 8:17 am 
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This is part of the new transforming of America, get used to it , SAD... I feel so sorry for anyone who needs Suboxone and can't get it ! (Edited personal attack. Amy)


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PostPosted: Sat Nov 02, 2013 1:02 pm 
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Insurance companies are denying these situations more and more these days. Since you are not an addict, Suboxone is being used 'off label' and insurance does not have to cover it. Check the price of Subutex and see if your doctor will prescribe that. Around here it is running about $80 per month.
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PostPosted: Sat Nov 02, 2013 2:14 pm 
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Thanks DOCM for the info. It always helps hearing solutions from a doctor.

Ambynyc, let me first welcome you to our forum. You won't need to use this place very much if you're not an addict like most of us are here. What docm suggested is a good one if they'll pay for it. Another medication is the Butrans Patch for pain. It has the same main ingredient of Buprenorphine but at a much lower dose. The strongest one available is 20 micrograms. It's roughly 2 mg's of Buprenorphine absorbed continuously over 24 hours. One patch lasts one week. You won't feel any effect from it but Bup in low doses seems to work well for pain.

I am a bit surprised that your insurance company wants you to go to 12 step meetings. How can it be proved that you attend them? My doctor is satisfied that I use this forum for my recovery. It has the same basic advice minus the 12 steps.

Let us know how it works out for you.

And Painter. Please keep the political views off the board. No one needs more aggravation. Thanks!

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PostPosted: Sun Nov 03, 2013 2:58 am 
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Saw a pain med doctor in my primary care physician's office today (yes, they had someone there on a Saturday!) and he advised the path that one of you mentioned-- going for the Butrans patch. He explained that he has had a great deal of difficulty getting Suboxone covered by insurance, and the only way they'll do it is if it's for addiction. Somehow my first 6 months got approved when someone wasn't reading the form carefully, and after 6 months of being on the drug I think it is sad that it isn't available for chronic pain patients because it's been working really well for me. You'd think the insurance company would be happy that I got off of Oxycontin (pretty easily abused on the street) compared to Suboxone that has the ingredient in it to make it useless to the average person trying to get high off of it. But no, it costs them more money and I was using it off-label and they're cracking down.

I'm thankful that I haven't had problems with addiction, have since my brother go through several iterations of that and it hasn't been pretty. Nevertheless, I am physically dependent on the medication and was extremely stressed out at the thought of having to do an unexpected and unplanned for cold turkey withdrawal, but feeling better since I got the script for the Butrans patch. Was on 8mg/2mg strips of Suboxone per day (1/2 strip in the AM and PM) and got a presciption for Butrans patch in 15 mcg/hr dosage. Doctor had a really hard time finding any information on comparing the two doses to find the right amount, so we're going to try this for a few days and I'll follow up on Monday to see if withdrawal starts and need to change the dose higher or lower if it's too much. So fun to always be a guinea pig!

I've heard some people complaining about not getting the same relief from Butrans as from Suboxone, but sounded like they were on too low of a dose after being opioid experienced. When I went off of Oxycontin 6 months ago, I was on 30mg 2time per day, so the doctor tried to figure out the dose of Butrans patch from there, but since then I went on the Suboxone 8mg films 2 times per day, and after a month was able to cut that in half and still manage pain levels. Doctor said I can't do anything to change the dose of the patch because of the way it's designed, so have to get a new script for a different dose if the 15 mcg/hr doesn't work right. I hope it does work, because it's clearly indicated for pain management and don't expect to have a big problem with the insurance company going forward.

Doctor asked if it was a possibility for me to pay out of pocket for a while and stay on the generic Suboxone, but even that is unreachable for me as the pharmacy quoted $153/mo and I live on SS disability, so that would be 15% of my check. Husband has income, but just took a paycut for better work/life balance, and it almost all goes to run our household and cover expenses for his daughter from his first marriage, 7 years left of child support and then we can have lives again!


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PostPosted: Sun Nov 03, 2013 10:24 am 
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The butrans patches are lower doses. I wonder if your insurance company would view generic bupe (without the naloxone) or subutex, the same as Suboxone..?

I'm glad your doctor is looking into options for you. Let us know how it goes.


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PostPosted: Sun Nov 03, 2013 12:56 pm 
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Ambynyc, please keep posting on how the transition goes from Suboxone to Butrans. I have tried it once and it didn't go so well. Some people have problems keeping the patch on for 7 days. You can use tegaderm or similar product to keep it in place.
Most insurance companies consider Butrans a tier 3 drug requiring prior authorization and failure or problems with at least two full agonist. Ironic, methadone is tier one and easy to get.
Butrans has a max dose of 25 mcg per hour and I am not sure if that will cover someone that has been on high doses of opiates in the past. That is the max the FDA has approved because of potential cardiac toxicity. Again, ironic, because methadone has shown the same side effect (torsades de pointes) and it has not been limited.
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PostPosted: Mon Nov 04, 2013 3:15 am 
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6 mo ago I was on 30 mg of Oxycontin twice a day, then did 3 days of withdrawal and switched to 2 8mg strips of Suboxone per day. After a month I was able to half that dose and still maintain pain management. When I tried to go any lower than that I had too much breakthrough pain. My doc wasn't exactly sure how to calculate the closest equivalent dose of the Butrans patch, but went with the 15 mcg.hr dose. From the info I could find, I think that's the closest we could get.

I started using the patch last night and felt a rush after having the patch on for a couple of hours, and a little nausea at times today. I live in CO and have a license for medical MMJ which has been helping to deal with side effects today. I'm a bit uncomfortable, but mostly normal after a night of good sleep and have been able to eat enough, so I think it's just the adjustment, not as bad as during other changes.

Checking in with the doctor tomorrow to see if we need to adjust the dose as I'm going to visit family on Wednesday and will be away for a week so I hope that I'm not feeling too offish by the time I have to get on the plane!

Looked up Subutex on the insurance pharmacy coverage, and it's listed with a warning that it will not be covered unless there is prior approval, probably the same problem I had with stayingon the Suboxone as the insurance company said it should not have been approved in the first place.


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