New insurance refusing to pay for meds!

Discussion in 'Fibromyalgia Main Forum' started by Bambi, Aug 20, 2005.

  1. Bambi

    Bambi New Member

    They just changed insurance where my husband works, seems to happen every or every other August. We've always gone for the PPO's and this is supposed to be one but the card say HMO. They say it is "like" a PPO but has the HMO title. I can't make any sense of that!

    Anyway, they filled the pain meds for us this month and then sent a letter saying they will not do it again unless our doctor calls them and explains on what basis he is prescribing the meds for our
    conditions.

    My husband has Diabetic neuropathy, a congenital back problem with Arthritis and bone spurs that is very painful as well as terrible knees. He had surgery done on one knee and it causes him more pain than the other one. Surgery for his back is very iffy and can either work (less than 50% chance) OR can leave him in severe pain that even the most potent narcotics will not treat.

    I have been on the same meds for at least 8 years and on this dose of everything since 2003 without having to adjust the
    amount of medication. No other insurance has refused or questioned our prescriptions. Our doctor is a pain specialist and has no complaints or judgements against him and hasn't in 40
    years probably.

    Needless to say I am really scared and worried, not only that I may have to go off the medication without anything to replace it but more so of returning to the HELL that was my so called life before the meds. I was in 24/7 agony for
    several years, inflated pulse and blood
    pressure, skin erruptions, panic attacks,
    insomnia, terrible knock me to the floor
    muscle spasms. I was very suicidal by the time I found the doctor that started me on the pain meds and when she moved referred me to my pain doctor.

    I do everything to the letter with my meds and many self help things as well;
    exercise, self hypnosis, heat, ice packs,
    linaments, massage, Epsom salts and Peroxide baths, vitamins, OLE, Fish Oil,
    Flaxseed Oil, Vitamin E, B Complex..and it has all, with the medication, made my
    life bearable.

    I can do my chores at home from laundry to my pets to cooking again after years of being too fogged and in too much pain to do anything. I am able to get out and go to a mall or to a family dinner which I couldn't before. I am teaching myself to draw and paint. I HAVE a life again where I didn't for so long, and was suicidal before I finally got help.

    This insurance place is huge. I called the recordings they have on various conditions and for Fibromyalgia you would
    not believe what they say. First off they call it Fibromyal-geea, like it was some
    new word. They claim we have inflamation
    and that's is mostly in YOUNG PEOPLE but
    also in some older ones. Just backwards of what is true. They advocate exercise
    and rest. If that doesn't help then they
    say to do the usual massage and a couple of other things. Then they say as a last
    resort some medications help like a muscle relaxer and antidepressants.

    Well antidepressants DO help some people I know, but they did NOTHING for my pain
    and I'm NOT depressed. Or wasn't until this. The off label use of the anti seizure meds didn't do a thing for me, nor did Chiro, Accupuncture, PT, TENS (I
    have an expensive paid for TENS machine
    sitting here collecting dust!) or any of the other things that help some but didn't me!! I HAVE tried everything, kept
    what DOES work for me and stopped the rest.

    Noone wakes up and says "Gee I think I want to take opiods the rest of my life"and neither did I. I was apprehensive at first. But I don't get any high, don't feel groggy the next day
    and ONLY feel relief of my pain and as a
    result able to function again! I do take
    Trazadone but it only works for sleep for me and does NOTHING toward my pain. The
    muscle spasms were as bad for me as the pain and every doctor who saw me having
    them said they'd never seen anything like
    them..they are that bad! So the muscle relaxer has been a God send also.

    My doctor will have to appeal this decision and I think we'll have to also,
    but I don't understand the first thing
    about it. I think they only give you five
    days to put in an appeal. If I had a printer and time I could find piles of
    information on how using pain meds is necessary for some FM patients with moderate to like mine, severe pain. I could get someone from the American Association of Pain Medicine to send me some brochures and info to give them, but there isn't time. Besides, they KNOW what all I've tried and that this works for me, it's all in my records!!

    They only use as authority for their judgements agencies that do NOT agree with opiods for FM pain. Of course, it saves them thousands of dollars not to have to pay for them! I guess they'd rather see patients like me go back to hunting up Kavorkians than to live a relatively normal life??!! It is beyond
    unfair and is very frightening and depressing to think of how my life will go backwards to NO life if they succeed in not paying. The pharmacies here won't
    let you pay cash, if the insurance won't
    pay for something, they won't fill it!!
  2. CFIDSNicole

    CFIDSNicole New Member

    First, this may not be as bad as it seems at the moment, so take a breath or two. When my husband changed jobs, our insurance changed (same insurance company, different plan and all that).

    When I went to fill my Cymbalta for the first time, they denied it and said they wouldn't pay for it until my doc called and explained why I am taking it.

    So, I called my doc and told her what the deal was; she called the insurance company, and then they paid for it. No more questions asked, no more problems

    So, maybe the whole process will be the same for you and they won't cause anymore problems. When this happend to me, I was livid (like you) and just so mad, but my hubby calmed me down and said, well, do what they want and let's see what happens. It worked out okay, and I think a lot of insurance companies do this, so I think it will be okay.

    take care
    Nicole
  3. Bambi

    Bambi New Member

    the kind words. They DO mean a lot to
    me! It's been a rough year with a lot
    of disappointments but the one constant was that I was feeling better than I even was a year ago. I've done more and more exercising and things around my house. It hasn't been a Utopia but it has really been such a joy to feel better at all.

    I've been surprised that I haven't had to increase or change my meds and thought if I did just what my doctor
    advised and was careful to follow all the rules the insurance companies would see my progress (or at least that I wasn't getting worse) and leave us alone. I've had some bad flares like we all do in times of big
    stress of heavy storms, but over all I've done well.

    I have been so aware of the dangers of some letting their medication be abused or stolen that I've taken the
    meds in a bag to our bedroom when we sleep at night. I've never once taken more than prescribed and usually less and never even 10 minutes early, though often late. I have been so grateful and respectful of my doctor's reputation and practice because he is such a compassionate man who really cares about his patients. Hopefully it will all be ok
    because I DO believe if you live with a grateful heart it usually does work out.

    I am worried about my husband too because I've seen a man that was always strong and independent cry from his pain for the first time in over 30 years. I've seen him limp off
    to his truck to go to work in the morning and come in after work totally exhausted from the effort of
    working in so much pain. I just hope these people who make such decisions
    have "some" degree of compassion, though I know insurance companies are
    pretty much non people and pro the bottom line. No matter what, I wouldn't wish chronic pain on any of them because I wouldn't wish it on my worst enemy...but it's tempting. LOL!

    Thanks again!!
  4. abbylee

    abbylee New Member

    Tell your husband to go to HR and complain. The company picks the insurance and what the insurance covers. The company can also tell the insurance folks to make an exception and if they tell your husband that they can't, they are not being truthful.

    I had a similar situation, and when my husband let them know how unhappy he was (unhappy employees make for sorry workers), they agreed to cover my drugs. (Initially our insurance paid 60% for my Xyrem because I couldn't get it at an "approved" pharmacy. When my husband explained to them that I get it from the ONLY pharmacy in the country that can fill it, they had a change of heart. It took a year of complaining, but they finally agreed to 80% like they pay for everything else. And once approved, they paid for the back bottles, too.)

    The only other thing our of the ordinary that we had to do had nothing to do with the insurance, but with the pharmacy. My doctor is in another state so in order for the pharmacy here to fill my Methadone rx, my doctor had to write a letter to DHEC (State health department), and explain why I was taking Methadone. (In this state they recently shut down some pain clinics for over-prescribing Oxycotin and they are giving daily Methadone doses (liquid) to the people to combat their addition to Oxycotin. Mine is pills and I get them once a month.) Once they received the letter they contacted the pharmacist and he has been filling them for 3 years as of now.)



    abbylee