I don't take this meds,BUT Lyrica & Cymbalta

Discussion in 'Fibromyalgia Main Forum' started by Empower, Jul 15, 2008.

  1. Empower

    Empower New Member

    Fibromyalgia patients fight insurers over medication coverage
    Sunday, July 13, 2008
    By Steve Twedt, Pittsburgh Post-Gazette
    Stacy Innerst/Post-GazetteWith the Food and Drug Administration's approval of a second fibromyalgia medication last month, you'd think the nation's estimated 10 million acute pain fibromyalgia sufferers would be delighted.

    Not quite.

    While welcoming any new treatment, patients also know that insurance companies have been slow to cover Lyrica, which won FDA approval a year ago, and probably will have similar reluctance with Cymbalta, an antidepressant now approved for treating fibromyalgia.

    "There have been some insurers who take the stand that if they make it more and more difficult for patients to get these medications, they will go away," said Lynne Matallana, president and founder of the nonprofit National Fibromyalgia Association.

    Insurance companies often do not consider Lyrica and Cymbalta medically necessary, and instead will stress lifestyle changes and steer patient to off-label pain relievers or alternative treatments such as relaxation techniques, physical therapy and biofeedback.

    "What they mean is 'fiscally necessary,' " said Dr. Leslie Tar, a local physician/attorney specializing in rheumatology who treats hundreds of fibromyalgia patients in the region. "They are using a financial definition for a medical problem."

    When Ms. Matallana's Fibromyalgia association sent e-mails two months ago asking members if they'd had trouble getting medication or finding a knowledgeable physician to help them, 800 people responded affirmatively the first weekend.

    "If you're really ill, it takes a lot of energy [to fill out a survey]. To have 800 people take the time to respond is quite extraordinary.

    "We're going to have to come up with a way to convince third party payers that by getting a diagnosis and getting treatment, we are actually reducing costs," said Ms. Matallana.

    This is not the first time doctors and their patients have disagreed with insurers about what medications or procedures should be covered. But this latest example illustrates growing tensions in the struggle between containing health-care costs and helping ill people feel better.

    Last year, Dr. Tar diagnosed Christine King, 57, of Carrick with fibromyalgia after she had suffered severe pain for two years. A doctor she had seen previously had attributed her pain to arthritis.

    "I had a lot of muscle pain and stiffness, and I couldn't turn my head. It was just a constant pain," she said.

    Dr. Tar prescribed both Lyrica and Cymbalta, as the medications work on different receptors in the brain. Ms. King went to her pharmacy, expecting to get the scripts filled for a $3 co-payment. "The pharmacist said the medication wasn't covered," she recalled. Her actual bill was close to $200.

    With Dr. Tar's assistance, she successfully appealed the insurer's decision before an administrative law judge. She says she started feeling better within days of taking the medications, though she eventually stopped taking Lyrica because it made her sleepy. Today, she says her pain is less than half what it was.

    "Illness is a fight in itself, and having to fight for medication just makes it tougher."

    Access to Lyrica is not a life-or-death proposition -- and not all patients say they feel better after using it. But it's not a budget buster for insurance companies either.

    Both Lyrica and Cymbalta treat fibromyalgia's main symptoms, an often-debilitating sensitivity to pain, rather than cure the disease. Diagnosis is made through an extensive physical exam; fibromyalgia cannot be detected by an X-ray or a blood test.

    Fibromyalgia's amorphous nature -- a New York Times story earlier this year raised the question of whether it is an actual disease -- and the highly individualized effectiveness of the medications no doubt play into the calculus of deciding not to cover even FDA-approved medications.

    But that misses the point, Dr. Tar said.

    "When I prescribe a medication and the insurance company says, 'no,' what am I supposed to do? I'm frustrated, and the patient is frustrated. They are limiting access to necessary medicine."

    He estimates that about 30 percent to 40 percent of his fibromyalgia patients have health insurance that covers the medications. The others are directed to the "therapeutic alternatives."

    "And, what do you know? Those therapeutic alternatives are generics and are very cheap," Dr. Tar said.

    "This is a condition that has a treatment, but the patients lack access to it because of financial concerns. For the first time in my life, I'm finding this is happening more and more."

    The FDA approves a medication only after it has been thoroughly tested and shown to be both safe and effective for treating a specific condition. Although FDA approval may make insurers more likely to cover a medication, FDA has no authority to make them cover it.

    Policies differ from insurer to insurer. Highmark administers many different policies, so some employers cover the medications and others don't.

    The UPMC Health Plan covers Lyrica, but requires prior authorization in which the physician must document the condition and previous attempts to treat it. The plan is still reviewing whether it will cover Cymbalta.

    Coventry Healthcare, parent company for HealthAmerica, also covers both medications, according to a company spokesman, adding that FDA approval does not "necessarily move the drug to a first line recommendation."

    But not all preauthorization protocols are created equal, said Dr. Tar. "I fight with [HealthAmerica] continually as a patient advocate, and they are the least liberal in allowing for Lyrica."

    While preauthorization is better than flat-out denial, Dr. Tar said it could have a similar effect if the process is too onerous.

    "Doctors are so busy, they are not interested in jumping through additional hoops. So they are being taught by the insurance companies to take the path of least resistance.

    "And that's exactly what the insurance companies want. It's about the money. It's a way to decrease costs by undermining access to medication."

    Steve Twedt can be reached at stwedt@post-gazette.com or 412-263-1963.
    First published on July 13, 2008 at 12:00 am

    [This Message was Edited on 07/15/2008]
  2. marti_zavala

    marti_zavala Member

    Interesting article - I have decided not to take these meds either.

    But I received a Cymbalta coupon from my doctor for the first prescription. It was free so it allowed me to try it.

    Perhaps this could help someone try it first before fighting the ins companies to pay for it.

    you may want to add Lyrica and Cymbalta to the title so you get more hits. Lots of people take them and some take both.

  3. msbsgblue

    msbsgblue Member

    My insurance said no and wanted to substitute Effexor instead. Good thing my husband read the enclosure since not even the pharmacist said it couldn't be taken with Ultram and I take Umtram.

    Could cuase death.

    I won't take cymbalta, effexor or lyrica.
  4. gapsych

    gapsych New Member

    My insurance company did pay for these medications. However, I had to quit both. I literally could not get out of bed on the Lyrica because of dizziness and it did not help my pain which the doctor said if I was going to see a difference I would have seen it by then. Cymbalta, revved me up so much that I had "manic like behavior", these were my doctor's words. Supposedly you are not bipolar if you get this reaction because of a drug.

    However I do well on the SSRI's and Zoloft has really been helpful with any depression and the pain.

    From what I have read, Lyrica is not that effective for most people but seems to be on the ones who can tolerate it.