Don’t look now… but the Medicare folks who are chronic pain pts are at risk of being sucker punched by their Part D and/or Medicare Advantage programs. Medicare open enrollment period is now open and closes on Dec 7th.
CMS has given these FOR PROFIT private insurance companies some dosing guidance on opiate and other controlled substances. This is where things get FUZZY… apparently these companies can put into effect any limits they wish up to the limits issued by the CMS.
Apparently – per CMS – there are soft edits at 90 MME and supposedly the pharmacist can override this fairly easily and then there is a HARD EDIT at 200 MME – NOT ABOVE 200 MME – so if you are taking MS Contin 100mg twice daily… you have hit the HARD EDIT – how stupid is that.
From what I understand once you reach the HARD EDIT level… is when the insurance companies DECIDES if you really need that high a dose… remember we are dealing with FOR PROFIT INSURANCE COMPANIES and denial of care of pt’s medication needs… will drop directly to their net profit/bottom line.
Now here is where pts may get really screwed… in about 10 days (Dec 7th) open enrollment ends for Medicare… BUT.. the insurance companies are not going to announce/publish their final dosing limits until maybe as late as Jan 1, 2019. So no matter what program that you are signing up for now… may end up being a “pig -in – a-poke” because what ever they claim is their policies may or may not have any relationship to what their policies are going to be come 2019. AND… you can’t make any changes to your insurance provider until the end of 2019 for 2020.
Back in jan , 2006 when Medicare Part D program was first implemented, maybe pts should consider this may happen again in 2019 when these new dosing guidelines are implemented. There was a lot of Medicare folks back in 2006 that showed up at the pharmacy on Jan 1, 20016 with their new Part D insurance card – out of medication – and expecting to get part of the medication costs covered.. Problem was this new system CRASHED… pharmacists in every store in every state… couldn’t get claims processed.
At that time, expecting something like this would happen … I made sure that Barb had enough medication to last until at least mid-January and when she need her refills… all of the “bugs” in the system had been worked out and refilled in a timely manner.
This year Dec 31st is a Monday and I would not be surprised to see some/many/all of these Medicare insurance programs will not publish their new dosing policies until that day.. and .. of course the next day being a national holiday… many pharmacies will be open but few/no prescriber’s office will be.
DEA law permits a prescriber to prescribe a 90 days supply of opiates and other controlled substances, state laws and insurance policies may or may not allow this.
I have already talked to our PCP about getting a 90 days supply of controls in Dec and he is fine with it.
Keep in mind that there are some 130 million people on Medicare medication program of one form or another.
This year Jan 1, 2019 is a TUESDAY, everyone is going to be coming back to work from a THREE – FOUR DAY weekend.
I would not be surprised to see these Part D programs to publish their NEW GUIDELINES late on FRIDAY Dec 28, 2018 and not be back in business until Jan 2, 2019. How many of those 130 million Medicare folks are going to be finding out that their controlled substance falls under some new dosing guidelines.. that they – and maybe their prescriber – don’t have a clue about ?
it is my recommendation to anyone needing a controlled substance filled the first of the year to talk to your prescriber and pharmacist and see if you can get 60 or 90 days supply in your state filled in December.
If the Part D implementation of 2006 is any indication of what could happen with this new implementation it could resemble a MAJOR CHAOS !!! It is not going to be business as usual. Pharmacies and prescriber’s offices could be TOTALLY OVERWHELMED at least the first week of Jan – which is a SHORT WORK WEEK !
Filed under: General Problems
I called medicare and was told that a 60 day notice must be sent out before any changes go into affect. I’m totally paranoid and worried that I won’t get my meds
Well, we can NEVER give up, and while we are in pain, we must get busy, make some noise, and never shut up. That is what THEY want us to do, and pain advocates are working overtime and donating lots of hours to the cause. I deal with this on a daily basis, have been doing suicide watches, etc. They want us to feel intimidated, the patients and the doctors who are not allowed to treat their own patients now. The gov’t is practicing medicine without a license. One very smart congressman went back to his state, for example, and decided to try some marijuana products to see what it was like. He is now going back to DC to tell his fellow politicians that they should all do what he did , so they are not voting on something they know nothing about. THAT is the way this should work always. I know I will never stop fighting, I got my SI joint fusion and stabilization surgery scheduled before the first of the year, and have discussed at length with both surgeons, my GP and neurologist. We have the plan worked out, but we could still get shut down on how we want to handle my post op pain. This is no joke.