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Insurance won't pay for increased dosage


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My insurance company (BC/BS, but I think the prescription coverage is Medco) has never batted an eye at some really crazy stuff my pdoc has prescribed - including a number of off-label meds. I've heard Provigil can be a bitch to get approved for anything other than narcolepsy, but they filled that without question. I take immediate release Adderall AND extended release Adderall. Same thing with Xanax - they always fill those without question.

But they won't fill a script for 8 mg of Rozerem 2x at bedtime because the manufacturer only recommends 8 mg. Or at least I think that's the reason. Which doesn't make sense because they will (and have) filled a script for 10 mg of Ambien 2x at bedtime (which, I believe, is twice what the manufacturer recommends). And at one point, I had a script for 90 mg of Cymbalta (30 mg more than recommended).

Is this just because Rozerem is so new? My pdoc is out of the office until after Labor Day. Is there any chance that a phone call from him will get them to approve it? When he upped my dose, he said that 16-24 mg of Rozerem have just about cured all but one of his hard-core insomnia patients (about 12).

I'm really annoyed because they (insurance company) will pay for 8 mg of Rozerem, 20 mg of Ambien, and 10 mg of Sonata (my current cocktail). I've found that with 16 mg of Rozerem, I don't need the Ambien and Sonata (I spent my vacation last week going off both of them).

At $3 each, I really don't want to have to pay for the extra dosage out of pocket. But I even more so don't want to go back on Ambien.

Grrr.

I need to call them directly myself. But in the meantime, any thoughts/ideas/suggestions?

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Blue cross is such a pain in the ass. I was going through the same thing. Can you pick a different pdoc in the interim and call the pharmacy number on the back of the card and have them fax the authorization to the new doc? They won't even cover me for more than one sleep med at a time so for me it's either ambien OR sonata OR Rozerem. I think rozerem is sort of new to their formulary thats why they're giving you trouble. I'm sorry I can't be of more help blue cross and blue shield are a pain.

Or maybe check out the pinned stuff for the sites that help folks with getting meds at a lower cost and have the new pdoc fill out a script from one of those.

lilie

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That's what's weird... they will cover scripts for all three of my sleep meds! They'll even cover scripts for 20 mg of Ambien (plus Sonata, plus Rozerem!). This is the first thing they've ever denied. I guess I shouldn't complain.

Pdoc will probably get me samples if I ask, too. I'll hold out until he's back - it's only a few more weeks. I guess it won't kill me to pay for one script out of pocket in the meantime.

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I live in Japan and so of course have no clue, but I've heard that insurance companies generally turn down most claims at first as a matter of course. This is just a first line of defense, so they can get off w/o paying folks who aren't together enough, for one reason or another, to reapply, bitch/yell/invoke drs etc.

Now I realize your situation is different than a regular one-shot claim, but this is my roundabout way of saying: can you simply re-apply? Maybe whoever was doing your claim will be on/vacation/sick/retired/on bathroom break when your next claim goes in, and someone else will get it and okay it for you?

lily

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But they won't fill a script for 8 mg of Rozerem 2x at bedtime because the manufacturer only recommends 8 mg. Or at least I think that's the reason. Which doesn't make sense because they will (and have) filled a script for 10 mg of Ambien 2x at bedtime (which, I believe, is twice what the manufacturer recommends). And at one point, I had a script for 90 mg of Cymbalta (30 mg more than recommended).

Is this just because Rozerem is so new? My pdoc is out of the office until after Labor Day. Is there any chance that a phone call from him will get them to approve it? When he upped my dose, he said that 16-24 mg of Rozerem have just about cured all but one of his hard-core insomnia patients (about 12).

Sunshine, this is very weird. Is there any way your pharmacist can tell the reason for the rejection? Seems like they should get a code of some sort or be able to call and see why. My pharmacists are cool and let me take the rx and then they figure out the reason and then I pay when it's all straightened out. Does the rx. coverage company have a web site? I can also go online and find out how much a rx will cost me ahead of time, perhaps you could get an idea of what's going on that way.

Let us know how you make out...

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OK. So... I work with computer systems and licensing stuff. AND I have been checking out scrip prices lately (Topamax y'know). So I think I have a clue what's going on.

It's likely that they're punching in your scrips, dosages, etc. into the system, and the sytem spits out your copays and whatnot. So far you've gotten good results, God knows why, maybe technically you shouldn't have but somewhere in this obviously complicated software something didn't connect. (Hey I hit one wrong button yesterday and it screwed up a new account that didn't get fixed today and MIGHT get fixed tomorrow so there ya go...).

Also. consider: the receipts from my pharmacy say that the list for my topamax is $362/month. When looking it up on the site for my prescription provider, yeah they have the copay the exact same but the list is like $270. So the important part is right but obviously something is fucked up.

So, this is where you call and attempt to reach a human being. An onerous task, I do agree (I've tried it on occasion, and yes, banged my head on the desk, even at work), but quite necessary. Determine the nature of the problem. Find out what it will take to fix--like, is it allowable to have that dosage covered at ALL, regardless of how the scrip is written? Is it indeed a software fart? Will you have to rent a U-Haul, buy some diesel and fertilizer?

And let's not forget the whole formulary/brand/blah blah shit, coered up to such-and-such amount then the rest is your responsibility and AGH! But yeah, call, only they can tell you.

Kinda like climbing the tallest peak to talk to the wise man. Just, not so wise, in this case.

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I will second calling and complaining to a real person. I've had to do this COUNTLESS times with BCBS. They didn't want to pay my therapist. They didn't want to pay my psychiatrist. They didn't want to pay for Risperdal they already agreed to pay for. It's happened before that the machine denied me for no reason and there was no trouble getting a person to agree to it.

If you're nice, but firm and a little indignant, there's usually a way to work things out.

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i've had kinda the same experience you've had with that company, where they don't question some odd stuff that is off-lable and even duplications but raise hell over something strange. they didn't want to pay for paxil cr, for example, and would only pay for the generic. my pdoc wanted the cr to avoid mania. he had a good reason. after he talked to them and i think reminded them of the cost of hosplitalization, they agreed. in my experience, reminding them of the cost of hospitalization and that i've had 5 of them is enough to get them to comply.

but it probably won't work just talking about our rozerem over here. i also take 16, but i get samples (i'm about to raise it to 24 if it doesn't start working soon. i'm turning into a real insomniac over here). give me ambien!

anyway...

i like the idea of trying to figure out why they rejected it. perhaps your pharmacist would know, or your pdoc could talk to them. i think that explaining that 8 won't work and you need 16 and not everyone always needs 8, just like not everyone always takes 20 of paxil but GSK "recommends" 20 would work. i think sometimes insurance companies are out to lunch.

it is strange that they've approved some odd things like that for you. when i had them they were easy on me but i never tried anything like that. but i did take 2 atypicals at once and they forked over the cash for those. again, i think pdoc's hospital threats could have been responsible ;)

EDIT- keep us updated! we love victories of the underdog over the huge insurance companies. i think you'll get them to do it.

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  • 10 months later...

Hi Sunshine,

Insurance companies can be surreal. They tried to limit my s.o. to only so much migraine medication per month. The same limit in milligrams no matter what the dose. She was able to fill out the form and get more, but she almost ran out. Maybe you can fill out some form or other. Or maybe just find out who is responsible for this decision and plant a hidden noisemaker that keeps them awake all night, preferably with out of tune Barry Manilow kareoke or something. ( I told my s.o. it would be nice if she could stand behing the cockroach responsible for that migraine policy and whack them over the head with a very large stick whenever she had an untreated migraine.)

Seems like insurance companies are a lot more interested in denying coverage than in saving money.

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