FURIOUS! Dr. won't call ins. co. to get approval on meds!

Discussion in 'Fibromyalgia Main Forum' started by TXPeach, Nov 12, 2008.

  1. TXPeach

    TXPeach New Member

    I am furious!!! I have been waiting for 3 whole weeks for my dr. to call my insurance company and explain to them why I MUST have sleep medication!

    I'll try to make this short. I was taking amitriptyline for years. It worked like a charm--helped with sleep and pain. I did so much better while I was taking it. My dr. had stressed to me how important it is for me to get good, quality sleep since I have FM, that I cannot get better unless I SLEEP!!!!

    Problem is I had to stop taking the amitriptyline because it caused such extreme dry mouth that it was ruining my teeth....12 fillings in one visit, and I am due for 4 more and 2 root canals.

    Anyway....so he switched me to Ambien which is wonderful. I can sleep and no dry mouth!
    The first time I had the prescription filled, no problem. I went back for a refill and the pharmacy told me that the ins. co. refuses to pay for it until the dr. calls and explains to them why I need it!

    Sooo...that was 3 weeks ago and about 6 calls to my dr.'s office!! They refuse to call the insurance co. and get this straight for me!!! WHY??!!! Or it's not that they refuse, it's that they are "so busy". GGGRRR!!!!! Meanwhile, I have not slept for longer than 2 hours at a time in 3 weeks!

    My pain is magnified. I am to the point that I can barely function. I am surprised that I can even sit here and type this.

    HELP!!!! What do I do????? It doesn't do any good to keep calling the dr.'s office. Any advice on what I should do, please??!!!

    God bless all of you. You have been my lifesavers.
    hugz to all,
  2. Janalynn

    Janalynn New Member

    So do you have an actual refill but the ins. won't pay for it? Can you pay cash? I have no idea how expensive it is..is it on Walmart's $4 list?

    If it were me...I'd call the pharmacy and ask for help. Of course, it depends on what kind of relationship you have with them. Have them call the dr's office saying they are waiting to submit this refill but can't.

    THEN, I'd go to the dr.s office, sweet as pie and beg. People respond to "I need your help" nicely (the first time ..or the 7th) Ask what YOU can do to help them - supply the ins. co #, who they should talk to directly, give them a name or whatever to make it an easy and quick phone call.

    What is it with the ins. co not covering your Ambien? Geez!!!! I bet you're frustrated!
    I wish I had more advice for you, but that's what I'd do.

  3. TXPeach

    TXPeach New Member

    Yes, that's correct. I have a refill, but ins. won't pay for it until the dr. calls them and explains to them why I need it. Yes, I could pay cash, but it is expensive, and why have insurance if I can't use it, ya know? I am so low on funds right now because of all of my trips to the dentist.

    I'm not sure if it is on Wal-mart's $4 list. Unfortunately, my prescription is at Walgreen's though.

    The other problem is that I live in the middle of nowhere. I am 75 miles from my dr.'s office, and he knows this. You would think he would be a little more helpful since I am so far away. I don't know whether to blame it on him or his staff!

    I am also that far away from a pharmacy so I have to carefully plan my refills so this is not good!

    Thanks for the great advice, Janalynn. I appreciate your taking the time to read this and try to help me. I just wish I had my ambien!


    P.S. Forgot to add that the pharmacy says they have faxed a request to the doctor 3 times with no response!
    [This Message was Edited on 11/13/2008]
  4. mom2many

    mom2many New Member

    Ambien runs about $150. but there is a generic that is about $15.00, I take Ambien and it helps me but the generic doesn't but all my other meds are generics and they work great for me.
    The other thing is Ambein CR, there is a coupon on there web site for 7 night for free and than $20.00 off your next 5 refills. And the Ambien CR is about the same price.
  5. TXPeach

    TXPeach New Member

    Thanks for the info, mom2many and Kina. I appreciate it.

    Kina...my dentist is helping me with the dry mouth issue. I am using a concentrated fluoride toothpaste and mouth rinse every day. I also use a sonicare toothbrush which helps.

    I faithfully floss every day and brush no less than 3 times a day. For the past 30 years, I have visited my dentist regularly every 6 months for a cleaning. However, now I am on a 3 month schedule due to all of the problems.

    I have always been meticulous about cleaning my teeth. That is why I was so devastated by the bad news I recently received about my teeth!

    As for the ambien, my dr. never told me it wasn't good to use long term. As a matter of fact, he gave me the script with 3 refills. I do not want to become dependent on it, but I don't know what else to do in order to get some sleep. What do you all do for sleep? How nice it would be to not have this problem!

    Thanks again, everyone, for the valuable info!
  6. goofgirl

    goofgirl New Member


    I also had problems getting my Ambien CR approved; I'd never been prescribed a medication that required "pre-authorization" meaning the Dr. had to call the insurance company before I could have it filled. It took a week to get mine, and the Dr. said he had to "work really hard" to get it approved for me. The approval is good for a year. The pharmacist said I actually got it approved pretty fast, normally it takes weeks. I thought, how sad it takes so long, when people are obviously being prescribed medication because they need it! It's $150 out of pocket without insurance.

    I realized this week that it DOES seem to cause dependence because i forgot to take it one night, and by the time I realized I hadn't taken it it was too late at night... I don't think I slept all night at all... I do sleep right through the night with it, though, it's definitely improved my sleep when I take it.

    I hate that there are so many side effects to all of these drugs we're given for the symptoms we have... makes you wonder which is worse, the disease or the side effects?? I hope you're able to get your prescription or find something else that works for you. Your teeth are so important, so you definitely don't what to do any more to hurt them.

  7. Leaknits

    Leaknits New Member


    Does your county have such a person as Head of Medical Services?

    You might have to call a hosp local to where you are to find out, if the phonebook where you live is as poorly set up as the one we deal with here in Lake County CA. When I need a number of any county or state office, I cringe...not only does the stink of the paper or whatever substance is used to print on it make my MCS rear its' head but I just all too often can't find what I need.

    Is your dr in a county clinic? It might be easier to get some attention from Medical Services head if the "so busy" people ARE working in a county clinic.
    I say that because I used county clinic services before I got tired of having to wait hours for a pre-set appt, also the fact I was doubted, sneered at, openly laughed at by drs and P A's, when I would begin to try to explain I am ill and in pain.

    I finally got tired enough of the shoddy treatment to complain. Turned out the County Medical Services Head was former PCP for me, actually liked me, and wasn't afraid to do his job.

    At least three of the mal-treaters no longer work in the local system.

    Just a thought.

  8. Zenith_Z

    Zenith_Z New Member

    Hi, I'm sorry you are having such a problem with your prescription. I tried ambien for awhile, but after awhile it caused cluster headaches and also I found I was up at night and didn't remember anything....

    For sleep I take Doxepin HCL 25mg. It is a very old antidepressant that they don't really use for depression any more as others took it's place and were better....the small dosage doesn't really do anything antidepressant wise, but sure helps me sleep. My doctor had given it to me years ago for sleep, but I was a little dopey in the moring on the drive to work so couldn't continue....now that I do not work when he suggested it I said fine, I'll try it again. I don't know if this is a lower dosage than then, but I do not have any sluggishness or problems waking in the morning with it this time.

    I also take Klonipin (generic clonazepam) which is both a muscle relaxor and anti-anxiety medicine (i think?) Anyway, i was to take one in the morning and one at night....it makes me too drowsy during the day so I just take at night which is ok by my dr....and they work fantastic together. There have also been times where I've been out of one and it seems that even with just the klonipin one night, or just the doxepin one night, I still sleep fine....for the first few days....then i need them both again.

    with the two of these I sleep better than I have in many many many years!

    I think both are pretty cheap......the doxepin is one of those three months for 4 bucks things at wal mart (safeway honored that for me, maybe walgreens would too?)

    And I wouldn't think that your insurance company could argue with "anti-depressants, muscle relaxors and anti-anxiety" medications for you --

    Hope this gives you ideas,
    Take care,
  9. TXPeach

    TXPeach New Member

    Good evening, everyone...I want to try to respond to everyone so hope this isn't too long.

    Jessica, thank you for your comments. I am so glad you got your meds approved! I have often had the same thoughts as you concerning side effects of all the meds we have to take. You are right though--my teeth are very important!

    BDTMU.....I am from a rural area in west Texas, not close to anything really. The nearest cities of any size at all would probably be Midland/Odessa. There's nothing out here, but wide open spaces...lots of ranch/farm land and cotton fields. I would love to move!

    Lea...no, my county doesn't have a head of Medical Services. Like I mentioned before, I live 75 miles from a doctor or a pharmacy. We have NOTHING in my county. The dr. I go to isn't in a county clinic. He is in a private practice with 4 other doctors. I really feel that his staff is mostly to blame for the ineptness.

    Zena...thanks for your response. I think you may be on to something. Maybe I need to start considering other alternatives as far as sleepy meds go. If my insurance won't pay for ambien maybe there is something else they WILL pay for.

    OK, grammy, so I called the pharmacy again this afternoon to ask about the generic form of ambien and how much it would cost if I pay out of pocket. Walgreens is telling me $52.99 for 30 tablets of zolpidem. I couldn't believe it! Doesn't that sound out of line to you?

    Kina, no I haven't tried replacement saliva, but I am certainly going to ask about that. It sounds like just the thing I need. Thank you for bringing that to my attention.

    I am sorry that you are in a flare and can't get the proper meds that you need. It just isn't right. Why is it so hard for some of us to get the meds we need? I don't understand. But what I really don't understand are insurance companies who try to dictate what we should and should not take. If a dr. prescribes it, then that means we need it! GGRRR!!! I am just so mad at my insurance for this. Why is it that it was no problem the first time I had it filled, but now they have decided not to pay for my refills?!! I don't get it!

    Thanks, everyone for your help. I truly appreciate all of you. I hope you all have a peaceful, pain-free night!
    warm hugz,
  10. LindaK1943

    LindaK1943 New Member

    Hi Peach, another Texan here. Is your Dr. sure the amitriptyline is what is causing the dry mouth? My dentist tells me every FM patient she works on has dry mouth. I have it really badly too.
    I just spent $1054 on one tooth a week ago. She has started me out on a full push to ease the dry mouth. There are all kinds of things on the market and some script stuff to help fight the tooth killer. Good luck with the ins. co. Sorry to hear you are having such a hassle. Doing without the sleep is awful. LindaK
  11. mom2many

    mom2many New Member

    That's crasy, $52.99 for 30 tablets of zolpidem when it's $15.00 here in DFW. Did you know a lot of pharmacy will price match?

    OK, here is what I have (it's just a "discount card" but it's better than nothing).

    this is there pricing tool, you can see how much a drug will cost at all your nearby pharmacies. Be sure to print out the prices out when you go to the pharmacy to make sure you get that price, sometimes they will price match and give the lowest price on that list.

    If you click Enroll on the left hand side you can fill out your info and print your card right than.

    Oh and they have mail order also that is a bit cheaper in most cases.[This Message was Edited on 11/14/2008]
  12. steenlynn

    steenlynn New Member

    Hi peach, yes i did have this same prob actually... but for a different med., cant remember which one tho.
    After the 3rd call from pharmacy telling me they could not refill, i went to the Dr's office. Unanounced. Plead with staff, and sat in waiting room till they faxd my ins. co.
    I picked up my rx on the way home. I was'nt rude, just there! lol
    I also was not an hour away, but desperate measures are required in desperate times. right?
    Sorry elavil is no longer an option for you, since it has stopped working for me, i have been in horrible pain...mosty neck and shoulders. The lyrica didnt work out for me.....i have never been so sick on a med before...and i am no med. lightwieght. I am sched for an atlas profilax apt next week. Maybe that will be my miracle....
    Hope you have a full nights rest soon, steen
  13. TXPeach

    TXPeach New Member

    Fredt, that is a good idea, thank you! I don't understand how Walgreens can charge that much when it is 1/4 the price everywhere else!

    Linda, that is interesting. I didn't know that most people with FM have dry mouth. I have dry eyes too. This is definitely something to discuss with my dr. Thanks for the insight!

    Mom...thank you so much for the info. I am definitely going to check it out. I just cannot afford the price Walgreen's is trying to charge whenever I have so much going on right now with other meds, my teeth, etc.

    Steen...that is where my worst pain is right now too--my neck and shoulders. I have posted about it numerous times recently. Please let me know how your atlas profilax appt. goes. I am so desperate for some relief!
    I am just so frustrated with my doctor's office. I have another call in. We will see if they call back. I love my dr., but if something doesn't change I am thinking about getting a new dr. They should be taking better care of their patients than this.

    My hubby is telling me to just pay the $52.99 so I can get some sleep. Now it has almost become "the principle of the matter" to me. I guess I am being stubborn, but if I don't do something now, then it will be the same problem whenever I get ready for my next refill....unless I get my dr. to change meds, something my insurance will pay for. When I pay $450 a month for insurance I think they should pay for my meds! GRRRRR!!!

    OK, I will stop complaining now. I hope you all have a great day! :)
    warm hugz,
    [This Message was Edited on 11/14/2008]
  14. mom2many

    mom2many New Member

    Have you tried the Fibro Sleep from here?
    Ambein is the only thing that helps me but when I don't have it I take Fibro Sleep, ZMA and GABA (I take this one all the time) and it does work, not like the Ambein but way better than other sleep RX's
  15. gapsych

    gapsych New Member

    Sometimes, a medication will be approved, if the code the doctor uses is different.

    My provigil which is often not approved, was because the doctor checked sleep disorder and chronic fatigue.

    This may not help your present situation of not being able to contact your doctor but it may help in the future.

    Good luck.

  16. dragon06

    dragon06 New Member

    Just wanted to make a point that drug prices may be different because some people are paying a co-pay when others are paying out of pocket. If you have insurance sometimes your drugs are cheaper just because of the insurance...I know I get a lower rate and then my insurance company gives me more back...so you might be getting your insurance provider's preferred rate even if it is lower than your co-pay.

    Going by the prices of the drugs I pay for (I get reimbursed after)that doesn't sound that out of the range for a new generic (the zolpidem).

    You can try and find another pharmacy that has it for a lower price and also you can see how your insurance company feels about covering the generic instead of the name brand. They are sometimes more forgiving about covering a cheaper (generic) version of your med rather than the name brand, so ask your pharmacy if they can check if your insurance company will cover the generic. And if they will they should be able to dispense the generic off the script that was written for the name brand.
    [This Message was Edited on 11/15/2008]
  17. TXPeach

    TXPeach New Member

    Thanks again for all of the wonderful advice. I am so blessed to have you all here to talk to!

    Grammy, thank you so much for your help. At this point, I am not physically able to make the loooooong trip to Dallas. The pain in my neck/shoulders is too severe. Maybe if and when I improve I might be able to. I am barely able to make it 75 miles and that is with my hubby driving. (He's the only person I have.) I will keep your dr. in mind though. Thank you again.

    I am going to look into moving my prescription to another pharmacy, somewhere that isn't so expensive. I also like the mail order idea. Not having to get out of the house and have my scripts delivered to me would be wonderful!

    I have also decided to pay my dr. another visit and explain what has been going on. He may not even be aware. If he isn't aware, he needs to be! The last time I talked to his nurse she was very snippy with me. He needs to know this!

    I am also going to order Fibro Sleep that Mom2many recommended. Thanks, Mom! Has anyone else tried it and had success with it?

    Thanks again everyone!
    soft hugz,

    [This Message was Edited on 11/15/2008]
  18. Beadlady

    Beadlady Member

    Melatonin to help you sleep? I take 3 mg. I kind of switch off between generic Ambien and the melatnin. It is pretty cheap and I generally get it at Walgreens along with my other vitamins as they have buy one get one free alot.

    Also check the sale ads too I see where some pharmacys give a gift card--I've seen them for $10.00 and up to $ 25.00 to transfer your script to their store.

    Worth checking into--I mainly see those special things in the Sunday paper ads.

  19. quanked

    quanked Member

    your ins. co why it was approved the 1st time and now it isn't? Have you asked this co. by who's authority it is denying you this med? I just asked a dr.'s office by who's authority it was denying my daughter her medical records (she left the area)? She rec'd her records by fax the next day.
    I would ask in writing. I would ask for copies of their guidelines, policies regarding medications. You might consider contacting your medical examiner on the state level as well as any agency regulating health ins. at the state

    You know, some drs. do not know what goes on at the front desk. You might want to talk to the office manager/supervisor or take it up with your dr. I do not think that a dr. can sign on, so to speak, to take care of your medical needs and then leave you high and dry. Ethics must be considered here. You can file a complaint against him. In my opinion, I think there is a breach of duty or medical neglect or both. It should no be this hard to get what you pay for. Your anger is totally justified. FYI...

    Welcome to the Texas Medical Board Home Page


    Services for Consumers

    Services for Healthcare

    Boards and Agency

    InformaciĆ³n en EspaƱol

    Laws, Rules and


    Online Registration

    Reports and Statistics

    Town Hall Meetings

    Useful Links

    Customer Service Hotline (800) 248-4062 (Texas only)
    Customer Service (512) 305-7030 (outside Texas)
    Customer Service E-mail verifcic@tmb.state.tx.us

  20. TXPeach

    TXPeach New Member

    Hello again, everyone. Beadlady, thank you for your suggestion. I would love to try melatonin, but I never have. The reason is because on the bottle it says not to take it if you have autoimmune disease/disorders. I have vitiligo and hypothyroidism which are both autoimmune so I am afraid to take it. I would be interested to know why this is the case. Does anyone know?

    Quanked, thank you so much for this valuable information. I have it written down, and I WILL be using it! For now, however, I have lost that "fighting spirit". I am in a terrible flare, the worst one in years. This is the first time I've been out of bed since Saturday. BUT, believe me, I am going to fight like I've never fought before to get these issues resolved as soon as I pull myself out of this flare. I just don't have it in me right now. :-(

    There are really two issues at hand here.....the issue with the insurance company trying to dictate to me what I can and cannot take AND the issue of the incompetence or refusal of my dr. and his staff to take care of me! The more I think about it, the more upset I get, and you are right, quanked, this IS a breach of duty/medical neglect. My question is would they do this to someone who has cancer????!!! It seems that it is those of us with FM who so often get pushed under the rug. Why???

    Thank you again, everyone. You all are my lifeline. I appreciate all of you and your helpful advice/suggestions. God bless.


    [This Message was Edited on 11/18/2008]
    [This Message was Edited on 11/18/2008]