Re: WE WON (Actiq)
- From: "cllmd" <cllmd@xxxxxxxxxxx>
- Date: Thu, 27 Sep 2007 15:41:23 GMT
Howdy, Mike!
"Mike Berkowitz" <mkberk@xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx> wrote in message
news:um6mf31juj8oh7rcdsctsl8l80hgo8duf9@xxxxxxxxxx
On Tue, 25 Sep 2007 16:55:40 -0700, "cllmd" <cllmd@xxxxxxxxxxx> wrote:
The suckers aren't at the door yet, but the paperwork came thru in our
favor.....the arbitration was binding, and they found that the insurance
must pay for the suckers.
more later......
thank you for putting up with me!
Lavon
A former doctor tried to get me Actiq but my insurance company said it
was only for cancer patients and that it must be prescribed by a pain
doctor. No exceptions.
How did you manage to win this one. Was it in CA?
Yes, i'm in CA. I started using them in late '99, when another headpain
person said they had been helping her so much. It took a few years to get
my dosage right, and to balance my other meds with it. In 2002 or so, i
slowly began getting outta the house a little. By '04, i was doing much
better. '06 was a busy year, even.
Was it PacifiCare?
(yes/no answer is all I need.)
Yep, PacifiCare/United Health(doesn't)care was the insurance my husband's
school district changed to in Jan. '07. However, apparently taking place in
'07 was some bill/law/something or other that allowed the insurances not to
have to pay for meds being used off-label.
I've had to appeal for the Actiq with each insurance chris has had. All had
allowed them after the first refusal....usually took about 10 days. Of
course, now the generic is out, and is made by the same company. It's the
exact same med, made at the same place with the same stuff and there is zero
difference. Even the writing on the med is the same.
Oral transmucosal fentanyl losanges....they allow me about 30% of a full
life again. It's been hell this year, living without them. I've gained
back about 30 pounds, and left our house maybe twice a month, for short
trips to the store.
It's gonna take a few weeks to get the situation cleared up...i was getting
them at a local pharmacy...checking with the insurance (waiting for them to
acknowledge receiving the state's decision) and such. Full fledged party
when i have the suckers in my hand (and in the safe.)
Did you have to pay for the arbitration?
No, but i did pay for a lawyer to adapt the initial letter to the state and
insurance company when United Hellscare said their two appeals were denied
and that the next step was state arbitration. The state pays for it, as it
goes thru the state insurance commissionor.
The lawyer's letter was worth the money. I heard from the state at least 3
times during the info-gathering stage. They hafta check thru everything to
make sure the state has jurisdiction and that all the ppwk is there and
such. Luckily, the insurance was as evil/lying/incompetant with the state
as they had been with us....made that stage last forever. They actually
lied to the state, telling them the school district had signed up with them
in such a way that the state had no jurisdiction (it's called self-employed,
where the insurance is simply a clearing-house, and the district actually
pays the bills.) We had to submit proof that this wasn't the case.
Once the ppwk was all lined up and all the correct boxes check-marked, my
case went onto the three docs. The three docs who decide are paid by the
state, so no bias can be claimed. The state said that once it went to the
docs, it should be about a month. It was a little over that (big surprise!)
I've had so much anger, and had no where to rightfully place it. Having a
med work so well for me....i've been looking, actively working with doctors,
since '87 to find a med. Found one! Then it got yanked. It's cruelty,
actually. I've had a cruel 9 months. The insurance is just going by the
book. A box of 30 of the suckers is $1400 ($2200 brand) and i use 4 bxs a
month. The pharmaceutical company that makes the suckers, Cephlon, has
labelled them for cancer pain only so they can charge that extra percentage
that a "cancer only" med can get away with.
I actually blame Cephlon more than the insurance. They had it labelled for
cancer to make the extra money....okay, they're a business...money is the
point. But then their drug reps encouraged doctors to start using Actiq for
chronic pain patients. I read a study that said 80% of Actiq prescribed in
'06 was for non-cancer pain patients...dunno about the numbers, but that's
what an article said. Then the law gets passed where the insurance doesn't
have to pay for off-label use meds. Cephlon didn't get Actiq approved for
non-cancer pain. It's Cephlon that did a dirty deed.
I've gotta imagine that Cephlon stock has plummeted this year, due to,
supposedly, 80% of their Actiq sales washing away. Others have gone thru
what i have, and most don't have the spouse advocate that i have in chris.
I wouldn't have been able to chase this to the state on my own. It would
make sense for the drug company to get it labelled for chronic pain also, to
get their sales back into place again.
Most insurances have Actiq/generic oral transmucosal fentanyl lozenges on
their formularies...with stipulations. U.H. does. But make sure it's going
to be covered for you before you get used to it.
Hope this answered ya, Mike. If you have any other questions, ask away!
deep peace,
Lavon
.
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