Of all the lame brain BS mess….. My insurance carrier is now claiming that MSContin is “not cost effective enough for ongoing treatment“….yet they have recommended either Duragesic or Opana ER as a possible replacement medicine. And as you know those two are highly more expensive than generic versions of MSCONTIN. None of it makes sense really ya know
We have always suspected that the cost of a pt’s therapy is more important than the appropriateness of the therapy. As far as I know, Opana ER has been removed from the market by FDA/DEA and there may – or may not – be a generic available.
Moving a pt from one opiate to another can be a very bumpy ride for the chronic pain pt.. if the new opiate works and getting to a dose that provides equal or better pain management than what the original med provided. Plus the pt may be forced to have multiple office visits and office visit charges out of his pocket while the “new” correct dose is determined.
All so the insurance company MIGHT BE ABLE to save some money in hopes that the pt will eventually be able to gain a adequate pain management.
Since one of the basics of the practice of medicine… is the starting, stopping or changing the pt’s therapy – which includes medications. So does it sound like in the particular situation this insurance company – or PBM – may be attempting to practice medicine without a license ?
Regardless if it is the insurance company or a PBM, both/each has a medical director… and if anyone is responsible within these organizations for the decision to change a pt’s therapy… who else has the legal authority and education within that organization but their medical director ?
Under the controlled substance act, no prescriber can legally prescribe a controlled substance for a person that they have not done a in person exam.. so is this organization causing the pt’s therapy to be changed… even if the pt’s own doctor does in fact prescribe the medication ?
It is also illegal for a prescriber to treat a pt in a state in which the prescriber is not licensed in and illegal to prescribe ANY MEDICATION in which they have not done a in person physical exam.
Is it just me, or does this appear to be a case of the company’s profits are more important that optimizing the pt’s quality of life ? Also who believes that this is the only pt out of their hundreds or thousands of chronic pain pts that they are doing the same thing to… to make more profits for the company ?
Filed under: General Problems
Can you tell us which ins company, or where this is happening, which state? I see there are new formularies coming out right now for express and caremark, dropping oxycodone ER. This is madness, how will there be time for patients to book and get appointments during the holidays to accommodate these changes? Most doctors have no idea what PBMs are up to, they are begging now for access to prior auth lists, and then of course reform of the entire prior auth process because of the delays it causes. So if someone is switched to another med, is the pharmacy able to handle this? Is there even supply in the supply chain? Gahhh…
Bridig, have you checked with Express Scripts and CareMark directly ? Never believe what you read on the internet, what you hear from the media.or word of mouth. Always go directly to the source.
If you have Medicare. You can go to Medicare.gov to see what medications every company covers. You can also see if there are restrictions.
some companies have “Cut a price deal” with the company that makes a abuse resistance – long acting – Oxycodone (Xtampza).. might want to check that out on their formulary. Otherwise, see if your doc will write and your pharmacy can fill a 90 days supply of Oxycontin in Dec.. then you won’t get caught in the “bum’s rush” in January to get a PA processed. If whatever med you end up on and it doesn’t work for you go back an APPEAL the denial of Oxycontin… they have an appeal process – they don’t have to tell you about it – unless you ask – and then they have to provide you the appeal process in writing.. Even if they deny all the appeals within the PBM and the one outside the PBM… if you are on Medicare/Medicaid there is a ALJ ( Administrative Law Judge) appeal – no cost to the pt and the more appeal levels you go thru.. the more likely you will get approved.
There are time limits on appeals. Do not wait to find out what the time limit is. If the time has passed. You lose your right to appeal.
Does this judge have any medical background. Or do you know the SSI number. I got it from the federal employee agent I lost it ,for help in a matter if being denied treatment? No one in my state will speak to me I live in Idaho. Thank in advance.
I have proof on one PBM I don’t have the ability to show you because there isn’t a photo option. But saving the Plan sponsor money is in their mission statement. I would IMHO, say the PBM negotiated a better rebate with the makers of the 2 meds they will cover, and it is in the form of a rebate.
suggest that everyone read this https://www.pharmaciststeve.com/?p=2631 this is how at least CVS Health/Caremark function in the real world and there was another post tonight about CVS Health/Caremark and Ohio https://www.pharmaciststeve.com/?p=27758 and most of these PBM’s are “monkey see monkey do” here is a article where Blue Cross was suing another PBM Express Scripts for not sharing discounts/rebates/kickbacks https://www.nytimes.com/2016/03/22/business/anthem-sues-express-scripts-over-cost-of-prescriptions.html
As things get crazier and crazier….
THIS is BULLSH-T,,, I say that because until Dr.Government bullied their way into practicing medicine,,We CPP’s went 1nce a year,,at least I did..I had to check into my pain doc,,1nce a year,,250 bucks,,my once deductible,,insurance paid nothing,,,Soo this argument is crap,,that we cost too much,,Dr.Government are the 1ns who FORCED all these forced visits,,peee in this cup etc,,,not us!!They’ve made it expensive to bitch about how expensive we are..Just like all the new definition to make us guilty of being ,”users,” or addicts,, because we take a medicine on a regular bases for medical necessity,,,Crap all crap,,maryw
They seem to only ve addressing the cost of the prescriptions. They are not saying anything about the cost of care.
The government does not require doctors to perform drug tests. But they are recommended. If I remember correctly, doctors have to see patients they prescribed opiates,to regularly. At least once every 90 days. Again, more frequent visits are recommended not required.
Maybe it is just me. But, no one is going to make me feel guilty. when I have done nothing wrong. I will not give others that power over me,and my life.