Jump to content


Click here to find a mentally interesting date at No Longer Lonely Keep Crazymeds on the air. Donate some spare electronic currency you have floating around The Cloud



Some Crazymeds mugs to help you wash down your meds. Get mugged for at Straitjacket T-shirts for more. 11oz mugs are $13. 15oz mugs are $14.
Mentally Interesting mug
Mentally Interesting
Medicated For Your Protection mug
Medicated For Your Protection
Team Bipolar mug
Team Bipolar
Brain Cooties Aren
Brain Cooties Aren't Contagious
Photo

How To Get Insurance Co To Pay For Brand Name Topamax?


  • Please log in to reply
18 replies to this topic

#1 missy

missy

    Amateur Psychopharmacologist

  • Members
  • PipPip
  • 342 posts
  • Diagnoses:Bipolar, Avoidant Personality Disorder, Agoraphobic, Panic Attacks, Migraines, PTSD
  • Current Meds:Generic Seroquel, topiramate, bupropion, clonazepam, Niravam (PRN)

Posted 20 March 2010 - 01:34 PM

If you want to be on the brand name of Topamax and not a generic, how do you get your pdoc to write the prescription in such a way that the insurance company / HMO / Medicare (in my case, an HMO, Humana) doesn't kick it back and say that they must fill it as a generic?

If it is for migraines, must the pharmacy fill it as a brand name if the pdoc writes DAW ("dispense as written") and demands brand name Topamax? Is migraine the only acceptable reason to fill it as a brand name? Are those of us who are mentally interesting doomed to generic Topamax?

With all the fuss over the varying incarnations of generic Topamax, I'm not sure I want to be part of the generic Topamax experiment and think I want to skip straight to brand name. If not, I'm considering getting my brand name from Canada and paying for it myself.

I *do* have problems with migraines, so I may be in luck there.

Thanks in advance.
  • 0
Current Meds: Seroquel, topiramate, bupropion, clonazepam, Niravam (as needed for panic attacks or public places).

Meds I have been on include but are not limited to: Abilify, carbamazapine, Celexa, Cymbalta, Depakote, Effexor, Klonopin, Lamictal, lithium, Neurontin, Niravam, Paxil, Prozac, Remeron, Seroquel, Strattera, Topamax, Trazodone, Wellbutrin, Xanax, Zoloft, Zyprexa, can't remember all of them.



Enable Crazymeds to keep ranting about being crazy and taking meds. Donate some spare electronic currency you have floating around The Cloud


Stick to your treatment plan with buttons and magnets. 2.25″ $4 & 3.5″ $4.50 at Straitjacket T-shirts Some designs available in packs of 10 and 100
Pile of Pills buttons at Straitjacket T-shirts
Pile of Pills
Vaccines
Vaccines Cause Immunity
Medicated For Your Protection magnets at Straitjacket T-shirts
Medicated For Your Protection
Mentally Interesting buttons at Straitjacket T-shirts
Mentally Interesting

#2 notfred

notfred

    Emergency Second Opinion

  • Members
  • PipPipPipPipPip
  • 5,095 posts
  • Diagnoses:check out signature
  • Current Meds:check out signature
  • Location:USA

Posted 20 March 2010 - 01:40 PM

Yes, if the script is for brand Topamax and says DAW then you only get brand. That does not mean your insurance will pay for it. Migraines are not a special case.

nf

Edited by notfred, 20 March 2010 - 01:41 PM.

  • 0

I am in full remission (296.36) from Depression. Insomnia, ADHD-PI, Epilepsy, and the Pseudoparkinsonian tremor are well controlled.

 

Psyc Meds: Forfivo XL 450 mg (Wellbutrin XL), Abilify 15 mg, (Aripiprazole), Eszopiclone 6 mg (Lunesta), Vyvance 70 mg, (dextroamphetamine) Levetiracetam 2,000 mg (Keppra), Propranolol ER 60 mg (Inderal)
PRN: Lorazepam 1-4 mg (Ativan), Alprazolam 1-2 mg (Xanax), Dextroamphetamine 10-40 mg (Dexedrine), Propranolol 20-40 mg (Inderal), Ondansetron 8 mg (Zofran)

Supps: Multi-vitamin/mineral, Vitamin D-3 2,000 IU, Omega-3-acid ethyl esters 4 g (Lovaza), Fish oil 1-4 g.

Dx: Depression, Insomnia, ADHD-PI, Epilepsy, Dyspraxia, Tremor

I also take allergy and diabetes + it's complications meds.

All doses are a daily total.


#3 Classically_James

Classically_James

    Would-be Neurologist

  • Members
  • PipPipPip
  • 1,041 posts
  • Diagnoses:see signature
  • Current Meds:See signature
  • Location:Virginia, USA

Posted 20 March 2010 - 03:23 PM

Call Humana and find out what Tier and what restrictions, if any, are placed on brand-name Topamax. Definately get your doc to check the DAW box, because that's the first step. Then the pharmacy submits it to Humana to be authorized, and if there is a restriction such as Prior Authorization, usually the pharmacy will fax the required paperwork from your insurance (Humana Medicare Part D) to your Pdoc. Then your doctor has to explain, on the form, why you medically need the brand-name drug instead of the generic. Then the doc faxes that form to Humana, and they make a determination in no more than 72 hours. If it is authorized, the pharmacy can fill it. If not, you're stuck with generic.

When open season starts on Nov. 15, 2010, you may want to look at the AARP Medicare Rx Plans. I have the AARP Medicare Rx Preferred plan, and it is the best Part D plan for psych meds. Check it out on Medicare.gov.....go to compare Part D plans. Plug in your drugs, and a bunch of plans will come up. Check the AARP ones out. Don't worry about the name, it's for all ages (I'm only 27). BUT if you have the Medicare Extra Help (subsidy) paying for your drugs, you can switch plans at any time. With my plan, I can get almost any brand-name psych drug just at my request, even if it has a generic, without any hassle. I could ask for brand-name Topomax, but I just haven't yet. Whatever you do, go to medicare.gov and check out the different plans. I checked out the Humana plans before I picked mine in 2008, and frankly, they suck. Good Luck!
James
  • 0

Diagnoses:

1. Major Depressive Disorder (MDD - atypical type)

2. Seasonal Affective Disorder (SAD)

3. Borderline Personality Disorder (BPD)(in partial remission)

4. Cotard's Delusion (removed prior to DSM IV in 1994(in partial remission)  

 

Medications:

1  Luvox (fluvoxamine) 100 mg BID 

2. Abilify (aripiprazole) 10 mg QAM 

3. Forfivo XL (bupropion) 450 QAM

4. Seroquel (quetiapine) 100 mg QHS

5. Xanax (alprazolam) 2 mg TID

6. Desyrel  (trazodone) 150 mg QHS 

7. Lunesta (eszopiclone) 3 mg QHS

8. Soma (carisoprodol) 350 mg TID


#4 missy

missy

    Amateur Psychopharmacologist

  • Members
  • PipPip
  • 342 posts
  • Diagnoses:Bipolar, Avoidant Personality Disorder, Agoraphobic, Panic Attacks, Migraines, PTSD
  • Current Meds:Generic Seroquel, topiramate, bupropion, clonazepam, Niravam (PRN)

Posted 20 March 2010 - 08:09 PM

Thanks. I will look into the AARP plans.

On the Medicare website, however, regarding all plans, there is this vague language when I enter Topamax and the generic version is encountered:

"You should be aware that some plans do not cover the brand version of a drug if the generic is available. If you purchase a drug that is not covered by the plan, you will pay the full price of the drug, and the amount you pay will not be counted toward your deductible or out of pocket cost limits."

As for calling Humana and asking them about tiers, frankly, I don't want to give them a heads-up. I consider insurance companies sneaky and underhanded.

I recently went through hell trying to get Humana to pay for Allegra-D, and the generic version, at that! This is because it contains the ingredients used in Sudafed, which are apparently also used to manufacture meth. I had to provide them with a litany of other medications I had tried for my allergies: prescriptions, over-the-counters, everything. Even a note from my own doctor wasn't enough to convince them. But I wouldn't give up and finally they acquiesced and I got my medication.

In the case of Topamax, I would rather know in advance what I am up against. I don't want to give Humana any heads-up as I feel they would take advantage of that, as well as notate any call I make to them in my file that I am sure they keep on me. And yes, I am paranoid. :mad:

But I really did think for some reason that for seizures or some such, that one cannot afford to screw around with, that brand-name Topamax was not questioned whatsoever. However, I do not have seizures, and I am new to Topamax, so I do not know. If migraines aren't a special case, what about seizures? Just curious.
  • 0
Current Meds: Seroquel, topiramate, bupropion, clonazepam, Niravam (as needed for panic attacks or public places).

Meds I have been on include but are not limited to: Abilify, carbamazapine, Celexa, Cymbalta, Depakote, Effexor, Klonopin, Lamictal, lithium, Neurontin, Niravam, Paxil, Prozac, Remeron, Seroquel, Strattera, Topamax, Trazodone, Wellbutrin, Xanax, Zoloft, Zyprexa, can't remember all of them.

#5 Serpens

Serpens

    Would-be Neurologist

  • Citizen Medical Expert
  • PipPipPip
  • 1,095 posts
  • Diagnoses:GAD w/Panic and Major Depression Symptoms
  • Current Meds:Emsam 6mg/24hr, .25mg Xanax prn

Posted 20 March 2010 - 08:15 PM

There are several levels of DAW:
-Physician Specified(Mandatory),
-Member Requested(you ask for it, prescription is written without physician spec),
-Pharmacist Substitution(Usually because they're out of the generic)

Humana utilizes four principal drug formularies in its plans (disregarding the fuckage that is State Medicaid). There is a Medicare formulary (which I will ignore), something called RxImpact which is asinine, a standard commercial three tier structure, and a standard commercial four tier structure (4th tier = Specialty)

In the two relevant formularies, brand Topamax is still a covered drug, however at a Non-preferred copay (Tier 3). The only restrictions appear to be for quantity limits - normal for drugs with wide dosing strengths.

While the specifics of your plan may vary, it appears they will pay for brand, however you will have a higher copay for it. Non-preferred copays for Tier 3 tend to range between $30-$100 or so per 30 day supply, with discounts for using a mail order pharmacy. It is exceptionally rare for commercial insurance to review tiering. I have only seen it present on extremely high quality employer-funded, larger scale plans.

If you are on Humana's Medicare program, either PDP or MAPD, Topamax is again a 3rd Tier drug. Copays range from $45-$95 for a 30 day supply. There is usually a small discount for mail service. There appear to be no prior authorization or step therapy edits in place. CMS mandates a tier cost sharing exception, which is granted on documentation of failure, intolerance or contraindication to ALL preferred formulary medications - if you're on Medicare, don't ask for this just because you want something - that's not a medical reason.

I have the AARP Medicare Rx Preferred plan


I know not its equal in any category - save certain MAPD plans sold under the Ovations/Secure Horizons/Evercare brands which are for all intents and purposes, the same plan for prescription drugs with Medical and Hospital tacked on.
  • 0

#6 Serpens

Serpens

    Would-be Neurologist

  • Citizen Medical Expert
  • PipPipPip
  • 1,095 posts
  • Diagnoses:GAD w/Panic and Major Depression Symptoms
  • Current Meds:Emsam 6mg/24hr, .25mg Xanax prn

Posted 20 March 2010 - 08:21 PM

Oh yes. Two solutions:

Call Member Services and ask if brand name Topamax is covered.

Or,

On your next fill, have your pharmacy try to fill for brand name. If the claim Rejects with code 75 or 70, the drug will not be covered without authorization. If the copay is too high, they can reverse it and fill for generic (keep in mind, pharmacies get charged for each attempt to process a claim. Hope your pharmacist likes you).
  • 0

#7 missy

missy

    Amateur Psychopharmacologist

  • Members
  • PipPip
  • 342 posts
  • Diagnoses:Bipolar, Avoidant Personality Disorder, Agoraphobic, Panic Attacks, Migraines, PTSD
  • Current Meds:Generic Seroquel, topiramate, bupropion, clonazepam, Niravam (PRN)

Posted 20 March 2010 - 09:27 PM

I have the AARP Medicare Rx Preferred plan, and it is the best Part D plan for psych meds.


Not to go OT here, but this plan likely will not work for me. I am on Medicare/Disability. I already pay $96.40 per month for Medicare Part D. I need a full plan with medical coverage, i.e., doctors, not just prescriptions. Your plan in my area costs an additional $35.10 per month. I will look into whether I can add it as supplemental coverage, but it is fairly expensive as most of my drugs I don't have a problem using the generic.

Back to the question at hand, I wonder what criterion an insurance company uses in order to give a customer brand name Topamax versus generic (assuming the brand name is what the doctor wrote on the prescription).

ETA: While I was writing this, Serpens posted.

There are several levels of DAW:
-Physician Specified(Mandatory),
-Member Requested(you ask for it, prescription is written without physician spec),
-Pharmacist Substitution(Usually because they're out of the generic)

Humana utilizes four principal drug formularies in its plans (disregarding the fuckage that is State Medicaid). There is a Medicare formulary (which I will ignore), something called RxImpact which is asinine, a standard commercial three tier structure, and a standard commercial four tier structure (4th tier = Specialty)

In the two relevant formularies, brand Topamax is still a covered drug, however at a Non-preferred copay (Tier 3). The only restrictions appear to be for quantity limits - normal for drugs with wide dosing strengths.

While the specifics of your plan may vary, it appears they will pay for brand, however you will have a higher copay for it. Non-preferred copays for Tier 3 tend to range between $30-$100 or so per 30 day supply, with discounts for using a mail order pharmacy. It is exceptionally rare for commercial insurance to review tiering. I have only seen it present on extremely high quality employer-funded, larger scale plans.

If you are on Humana's Medicare program, either PDP or MAPD, Topamax is again a 3rd Tier drug. Copays range from $45-$95 for a 30 day supply. There is usually a small discount for mail service. There appear to be no prior authorization or step therapy edits in place. CMS mandates a tier cost sharing exception, which is granted on documentation of failure, intolerance or contraindication to ALL preferred formulary medications - if you're on Medicare, don't ask for this just because you want something - that's not a medical reason.



Serpens, thanks for the details. I did run into a problem with the generic Topamax and quantity limits. Since I am titrating upward, my pdoc wrote for 120 of the 25 mg tablets. Humana rejected. I asked the pharmacist to resubmit for half the amount and it went through. (I hope they like me! I think they do.) I am on one of Humana's crappiest programs, Humana Gold Plus. That program used to have what Humana formally called tiers, but Humana no longer calls them tiers (at least not to us patients). I would have to review my literature to see what verbage they use. Thank you very much for the explanation of Humana's drug formularies and also for the in-depth explanation of DAW. From what you have said, it sounds like if I want to try for DAW I need to request physician-specified and see if Humana honors it or rejects it.

From what I gather, you are saying that if my doctor writes "DAW" as medically necessary per the doctor, then Humana should honor it, regardless, and charge me a higher co-pay. Humana should not reject it at all, under any circumstances, if I understand you correctly.

Edited by missy, 20 March 2010 - 09:57 PM.

  • 0
Current Meds: Seroquel, topiramate, bupropion, clonazepam, Niravam (as needed for panic attacks or public places).

Meds I have been on include but are not limited to: Abilify, carbamazapine, Celexa, Cymbalta, Depakote, Effexor, Klonopin, Lamictal, lithium, Neurontin, Niravam, Paxil, Prozac, Remeron, Seroquel, Strattera, Topamax, Trazodone, Wellbutrin, Xanax, Zoloft, Zyprexa, can't remember all of them.

#8 missy

missy

    Amateur Psychopharmacologist

  • Members
  • PipPip
  • 342 posts
  • Diagnoses:Bipolar, Avoidant Personality Disorder, Agoraphobic, Panic Attacks, Migraines, PTSD
  • Current Meds:Generic Seroquel, topiramate, bupropion, clonazepam, Niravam (PRN)

Posted 20 March 2010 - 09:37 PM

Oh yes. Two solutions:

Call Member Services and ask if brand name Topamax is covered.

Or,

On your next fill, have your pharmacy try to fill for brand name. If the claim Rejects with code 75 or 70, the drug will not be covered without authorization. If the copay is too high, they can reverse it and fill for generic (keep in mind, pharmacies get charged for each attempt to process a claim. Hope your pharmacist likes you).


I see. I initially misunderstood. I was thinking you meant that if I had Humana, they would cover brand-name Topamax and charge me a higher co-pay (higher tier). But it sounds like it depends on which Humana plan I have.

I will call Humana and ask.

At my pharmacy's prices, it is probably going to end up being cheaper for me to pay for it out-of-pocket and get it from Canada. Still not sure why our drugs are so damned expensive, but that is another topic!
  • 0
Current Meds: Seroquel, topiramate, bupropion, clonazepam, Niravam (as needed for panic attacks or public places).

Meds I have been on include but are not limited to: Abilify, carbamazapine, Celexa, Cymbalta, Depakote, Effexor, Klonopin, Lamictal, lithium, Neurontin, Niravam, Paxil, Prozac, Remeron, Seroquel, Strattera, Topamax, Trazodone, Wellbutrin, Xanax, Zoloft, Zyprexa, can't remember all of them.

#9 dymphna

dymphna

    Ready for the MCAT

  • Citizen Medical Expert
  • PipPipPipPip
  • 4,471 posts
  • Diagnoses:Suck-Ass Epilepsy, Perma-Migraine, Endocrine Hell, Associated Mood Crap
  • Current Meds:LTG 600, TPA 500, CLZ 1.5-2, Dostinex 0.5, Zoloft 0.25-.5
  • Location:A Mac Computer

Posted 20 March 2010 - 11:41 PM

There are several levels of DAW:
-Physician Specified(Mandatory),
-Member Requested(you ask for it, prescription is written without physician spec),
-Pharmacist Substitution(Usually because they're out of the generic)


And then there is the lovely "we're not paying for it w/o talking to the doctor".

(doctor calls insurance company immediately and says it is for seizures)

"We're not paying for it".

(doctor threatens to see insurance company in court when patient lands in hospital)

"We're not paying for it".

Patient gets back on plane (had flown 8000 miles to see former neurologist just to get records straight), hands Rx to different pharmacist, no one questions it, and it is filled as ordered (brand).

When I next have to deal with this (in about a year) I will have to go through a horrifically long process with my insurer wherein I get a letter that forces them to pay for brand (from THEM). A letter that they will then say they never wrote and I will periodically have to fax to them. I have already had to do this with another medication.

I wouldn't be such an ass about it except that this isn't normal insurance - this is partial payment for a head injury I received that contributes to my seizures. If the medicine stops or lessens them, by god, they have to pay for it.


d
  • 0

Yes, my name really is Dymphna.

 

I'm not a doctor, nurse, pharmacist, or therapist.

I can find you an answer and I won't blow smoke up your ass.

 

St. Dymphna is the Patron for brain maladies.

 

I'm the Enforcer.

 

eqnmrt.jpg

 


#10 Classically_James

Classically_James

    Would-be Neurologist

  • Members
  • PipPipPip
  • 1,041 posts
  • Diagnoses:see signature
  • Current Meds:See signature
  • Location:Virginia, USA

Posted 21 March 2010 - 12:10 AM

Missy,

Sorry, I didn't know you weren't looking for just Part D. I was confused.
Jamers
  • 0

Diagnoses:

1. Major Depressive Disorder (MDD - atypical type)

2. Seasonal Affective Disorder (SAD)

3. Borderline Personality Disorder (BPD)(in partial remission)

4. Cotard's Delusion (removed prior to DSM IV in 1994(in partial remission)  

 

Medications:

1  Luvox (fluvoxamine) 100 mg BID 

2. Abilify (aripiprazole) 10 mg QAM 

3. Forfivo XL (bupropion) 450 QAM

4. Seroquel (quetiapine) 100 mg QHS

5. Xanax (alprazolam) 2 mg TID

6. Desyrel  (trazodone) 150 mg QHS 

7. Lunesta (eszopiclone) 3 mg QHS

8. Soma (carisoprodol) 350 mg TID


#11 Serpens

Serpens

    Would-be Neurologist

  • Citizen Medical Expert
  • PipPipPip
  • 1,095 posts
  • Diagnoses:GAD w/Panic and Major Depression Symptoms
  • Current Meds:Emsam 6mg/24hr, .25mg Xanax prn

Posted 21 March 2010 - 11:49 AM

I recently went through hell trying to get Humana to pay for Allegra-D, and the generic version, at that! This is because it contains the ingredients used in Sudafed, which are apparently also used to manufacture meth. I had to provide them with a litany of other medications I had tried for my allergies: prescriptions, over-the-counters, everything. Even a note from my own doctor wasn't enough to convince them. But I wouldn't give up and finally they acquiesced and I got my medication.

This is because there is an OTC version of Allegra-D. Medicare is absolutely an in ironclad terms prohibited from paying for OTC medications. Your insurance company can be fined up to around $25,000 per fill of an OTC. This massively, massively complicates dealing with drugs that have OTC versions.

The other issue is that Medicare does not permit patients to submit this sort of information. It can come from two people - your doctor, or someone who your doctor has appointed to represent him by giving them access to your medical records. Again, astronomical fines for violation


Not to go OT here, but this plan likely will not work for me. I am on Medicare/Disability. I already pay $96.40 per month for Medicare Part D. I need a full plan with medical coverage, i.e., doctors, not just prescriptions. Your plan in my area costs an additional $35.10 per month. I will look into whether I can add it as supplemental coverage, but it is fairly expensive as most of my drugs I don't have a problem using the generic.


Medicare's not going to allow you to have two simultaneous Part D coverages. What you could do is swap your insurance plan to what's called MA-Only (Medical and Hospital only), and get your Part D through an 'indepedent' plan, like the Medicare Rx preferred. This means you will have two cards - one for your medical, and one for your drugs.

Alternatively, there are MAPD plans (A+B+D) that basically are that same as that preferred plan.

This can get really confusing. It gets even messier when you have drugs that are covered as a medical benefit. I spend all day sorting this crap out.


Serpens, thanks for the details. I did run into a problem with the generic Topamax and quantity limits. Since I am titrating upward, my pdoc wrote for 120 of the 25 mg tablets. Humana rejected. I asked the pharmacist to resubmit for half the amount and it went through. (I hope they like me! I think they do.)

From what I gather, you are saying that if my doctor writes "DAW" as medically necessary per the doctor, then Humana should honor it, regardless, and charge me a higher co-pay. Humana should not reject it at all, under any circumstances, if I understand you correctly.


The rational is that, why take two 25 mg tabs when you can take a 50mg? It's frequently cheaper, it's easier for the patient, has better compliance, and better success. So your plan sticks a quantity limit 'edit' on that drug to stop things like... doctor's writing for 24 Lyrica 25mg instead of two 300mg. In that specific example, lyrica costs by number of pills, NOT by the dose in the pills (25mg and 300mg cost approx the same). You get idiotic doctors who are flat out [b]unaware[b] that they make higher dose pills.

Quantity limits are easily overridden for titration. I mean easy. Takes about ten minutes to process, requires a diagnosis, directions for use that the describe the titration - actually that's about it really.
  • 0

#12 Serpens

Serpens

    Would-be Neurologist

  • Citizen Medical Expert
  • PipPipPip
  • 1,095 posts
  • Diagnoses:GAD w/Panic and Major Depression Symptoms
  • Current Meds:Emsam 6mg/24hr, .25mg Xanax prn

Posted 21 March 2010 - 11:52 AM

From what I gather, you are saying that if my doctor writes "DAW" as medically necessary per the doctor, then Humana should honor it, regardless, and charge me a higher co-pay. Humana should not reject it at all, under any circumstances, if I understand you correctly.


Writing DAW doesn't establish medical necessity. Very few insurance companies discriminate between patient requesting brand, or doctor requesting brand.

What it comes down to is if you've purchased an insurance plan that provides coverage for this particular brand name drug.

From what I can tell on their website and provided documentation, Humana's formularies do cover it, without restrictions, but at a higher copay - regardless of who asks for the brand name.


And let me put it this way, working in Prior Auth has been.. educational in the extreme.
  • 0

#13 missy

missy

    Amateur Psychopharmacologist

  • Members
  • PipPip
  • 342 posts
  • Diagnoses:Bipolar, Avoidant Personality Disorder, Agoraphobic, Panic Attacks, Migraines, PTSD
  • Current Meds:Generic Seroquel, topiramate, bupropion, clonazepam, Niravam (PRN)

Posted 29 March 2010 - 02:40 PM

Serpens, thanks for the details. I did run into a problem with the generic Topamax and quantity limits. Since I am titrating upward, my pdoc wrote for 120 of the 25 mg tablets. Humana rejected. I asked the pharmacist to resubmit for half the amount and it went through. (I hope they like me! I think they do.)

From what I gather, you are saying that if my doctor writes "DAW" as medically necessary per the doctor, then Humana should honor it, regardless, and charge me a higher co-pay. Humana should not reject it at all, under any circumstances, if I understand you correctly.


The rational is that, why take two 25 mg tabs when you can take a 50mg? It's frequently cheaper, it's easier for the patient, has better compliance, and better success. So your plan sticks a quantity limit 'edit' on that drug to stop things like... doctor's writing for 24 Lyrica 25mg instead of two 300mg. In that specific example, lyrica costs by number of pills, NOT by the dose in the pills (25mg and 300mg cost approx the same). You get idiotic doctors who are flat out unaware that they make higher dose pills.

Quantity limits are easily overridden for titration. I mean easy. Takes about ten minutes to process, requires a diagnosis, directions for use that the describe the titration - actually that's about it really.


Serpens, regarding overriding quantity limits, is this something that I need to describe to my pdoc? To tell him I need him to override my quantity? Because he just keeps telling me to split the tablets.

I don't want to split the tablets due to conflicting information I have found on splitting topiramate which I will get into in a separate topic in the Topamax forum.

But for purposes of this conversation, one source says they "lose their effectiveness quickly when broken, so you should swallow them whole." My pdoc thinks it is fine to break them. Maybe it is. Not to argue with him, but with the conflicting info out there, I would just as soon swallow them whole.

How likely is it that my pdoc knows how to override a quantity limitation? Especially when he (stupidly) told the pharmacy (and they now have it written in my prescription) "no more 25 mg tablets." He already phoned in next month's supply of 50 mg tablets, and if I can't handle them I am supposed to split the tablets. No thank you.

If it takes 10 minutes to override, it sounds simple enough. But my pharmacist never volunteered that a quantity limit is something that is easily overridden for titration; he only told me that my insurance company denied it, even though I told him I was titrating. And I don't know if my pdoc knows the procedure to use.
  • 0
Current Meds: Seroquel, topiramate, bupropion, clonazepam, Niravam (as needed for panic attacks or public places).

Meds I have been on include but are not limited to: Abilify, carbamazapine, Celexa, Cymbalta, Depakote, Effexor, Klonopin, Lamictal, lithium, Neurontin, Niravam, Paxil, Prozac, Remeron, Seroquel, Strattera, Topamax, Trazodone, Wellbutrin, Xanax, Zoloft, Zyprexa, can't remember all of them.

#14 missy

missy

    Amateur Psychopharmacologist

  • Members
  • PipPip
  • 342 posts
  • Diagnoses:Bipolar, Avoidant Personality Disorder, Agoraphobic, Panic Attacks, Migraines, PTSD
  • Current Meds:Generic Seroquel, topiramate, bupropion, clonazepam, Niravam (PRN)

Posted 29 March 2010 - 03:14 PM

I recently went through hell trying to get Humana to pay for Allegra-D, and the generic version, at that! This is because it contains the ingredients used in Sudafed, which are apparently also used to manufacture meth. I had to provide them with a litany of other medications I had tried for my allergies: prescriptions, over-the-counters, everything. Even a note from my own doctor wasn't enough to convince them. But I wouldn't give up and finally they acquiesced and I got my medication.

This is because there is an OTC version of Allegra-D. Medicare is absolutely an in ironclad terms prohibited from paying for OTC medications. Your insurance company can be fined up to around $25,000 per fill of an OTC. This massively, massively complicates dealing with drugs that have OTC versions.


Actually, I have been unable to come up with an OTC version of Allegra-D. I am on the 12-hour version.

I do not mean a substitute drug, such as Claritin-D with different ingredients. Claritin-D does not work for me.

Allegra-D 12-hour contains fexofenadine and pseudoephedrine. Pseudoephedrine is the drug which is found in OTC Sudafed. But the combination of fexofenadine and pseudoephedrine, in an extended release formula, is not found in any OTC medication that I have found in the United States.

Plain old Allegra (fexofenadine only) is an OTC drug, but it is not time-released in the form I have found. And pseudoephedrine can be found as OTC Sudafed and related medications. But a 12-hour or 24-hour Allegra-D, even a generic, I have not found as OTC.

Medicare, and thus Humana, generally give a long runaround approval process to any drug containing pseudoephedrine. I'm guessing it is due to the history of the drug's illegal use in meth labs. For any prescription drugs containing psuedoephedrine they want to know I have tried other alternatives. Once I had proven that to them, they approved my request. But it was like jumping through hoops.
  • 0
Current Meds: Seroquel, topiramate, bupropion, clonazepam, Niravam (as needed for panic attacks or public places).

Meds I have been on include but are not limited to: Abilify, carbamazapine, Celexa, Cymbalta, Depakote, Effexor, Klonopin, Lamictal, lithium, Neurontin, Niravam, Paxil, Prozac, Remeron, Seroquel, Strattera, Topamax, Trazodone, Wellbutrin, Xanax, Zoloft, Zyprexa, can't remember all of them.

#15 creepy

creepy

    Would-be Neurologist

  • Members
  • PipPipPip
  • 1,685 posts
  • Diagnoses:MDD
  • Current Meds:200mg sertraline 300mg lamotrigine
  • Location:Hell

Posted 29 March 2010 - 05:15 PM

Im really curious to hear what your response is to brand and generic topamax. Although I know our responses to this drug are worlds apart, it might give me some ideas.
  • 0
Zombiez ate my brain
and spat it back out, blecch...

#16 Serpens

Serpens

    Would-be Neurologist

  • Citizen Medical Expert
  • PipPipPip
  • 1,095 posts
  • Diagnoses:GAD w/Panic and Major Depression Symptoms
  • Current Meds:Emsam 6mg/24hr, .25mg Xanax prn

Posted 29 March 2010 - 09:18 PM

I apologize, I made a mistake and you are correct. Fexofenadine + Psuedoeph has no OTC equivalent, only pure fexofenadine.

Truth be told, I've never had an issue relating to any of the later generation histamine antagonists and any of the Medicare programs I interact with. I do not believe they require any sort of authorization or have any edits - but I'll verify that tomorrow. This may be something that's a facet of Humana in particular.

I have had significant issues relating to loratadine, fexofenadine and cetirizine, and their respective psuedoephedrine containing partners on many union, medicaid, and small-business commercial insurance plans - which have them structured in asinine step-therapy chains that are simply asinine to get through.

As for overriding a quantity limit, it must be done via prior authorization.
http://apps.humana.c...sp?file=1313104

This is Humana's PA form. It really really REALLY sucks. Basically, your doctor fills it out, note the directions for use should include directions for titration.
Notate on it that it's a "request for prior authorization to exceed plan quantity limitations on Topamax (whatever mg) for titration purposes."

Fax form. 72 hour turn around time under CMS regs for complete requests (eg, Diagnosis is not optional, NPI is not optional etc.)

Also, it must be filled out by your doctor, or someone at your doctor's office who is 'appointed' (eg, has access to your medical information and records). Neither your pharmacist or yourself can fill it out under Medicare's rules.
  • 0

#17 missy

missy

    Amateur Psychopharmacologist

  • Members
  • PipPip
  • 342 posts
  • Diagnoses:Bipolar, Avoidant Personality Disorder, Agoraphobic, Panic Attacks, Migraines, PTSD
  • Current Meds:Generic Seroquel, topiramate, bupropion, clonazepam, Niravam (PRN)

Posted 30 March 2010 - 01:02 PM

This is Humana's PA form. It really really REALLY sucks. Basically, your doctor fills it out, note the directions for use should include directions for titration.
Notate on it that it's a "request for prior authorization to exceed plan quantity limitations on Topamax (whatever mg) for titration purposes."

Fax form. 72 hour turn around time under CMS regs for complete requests (eg, Diagnosis is not optional, NPI is not optional etc.)

Also, it must be filled out by your doctor, or someone at your doctor's office who is 'appointed' (eg, has access to your medical information and records). Neither your pharmacist or yourself can fill it out under Medicare's rules.


Serpens, thanks for including a link to the form. I have a few q's about the form.

What is a J-Code?

What is an ICD-9 Code?

What are mine likely to be, if I am bipolar?

Question number six asks, "Please list therapeutic alternatives previously used with start/end dates and outcome." Are they seriously asking him to basically list every medication he has used on me for bipolar ... ?? That could take him awhile to fill out ..... ! Just because he wants to titrate me on a drug? I really do not understand the reason for this question at all. Thanks.
  • 0
Current Meds: Seroquel, topiramate, bupropion, clonazepam, Niravam (as needed for panic attacks or public places).

Meds I have been on include but are not limited to: Abilify, carbamazapine, Celexa, Cymbalta, Depakote, Effexor, Klonopin, Lamictal, lithium, Neurontin, Niravam, Paxil, Prozac, Remeron, Seroquel, Strattera, Topamax, Trazodone, Wellbutrin, Xanax, Zoloft, Zyprexa, can't remember all of them.

#18 Serpens

Serpens

    Would-be Neurologist

  • Citizen Medical Expert
  • PipPipPip
  • 1,095 posts
  • Diagnoses:GAD w/Panic and Major Depression Symptoms
  • Current Meds:Emsam 6mg/24hr, .25mg Xanax prn

Posted 30 March 2010 - 04:35 PM

J-Code has to do with medical billing for Medicare Part B. Basically, if your doctor administers a medicine to you as part of a visit (like say, chemo), it's billed with a J-Code. Ignore it, it's not relevant.

ICD9 is a 3-5 digit number usually written in the form XXX.XX. It describes a diagnosable disease. For instance, unspecified essential hypertension is 401.9, Acid Reflux is 530.81. They can describe a disease in various detail, for example there's a different code for bipolar I if your last episode was manic, than if your last episode was depressive. For general purposes, the 'unspecified' forms are most common.

Bipolar and Major Depression are all under 296.* http://www.icd9data....296/default.htm
Migraine is all under 346.* http://www.icd9data....346/default.htm
The general catch all code would be 346.9 for Migraine.

This is a useful system because it basically accurately, swiftly and succinctly describes a diagnosis, though it has its limitations - for instance there is no code for adult ADD.

Question 6 does not really apply to this situation, you're right. Not applicable. If you were asking for a non-formulary(not covered) medication, you would list the medications you'd tried here, or if you were asking for cost-sharing(reduced copay), or for a medication that has a step therapy requirement (eg, try the cheaper med first). For your purposes, I would write here, "Not applicable, for titration purposes to reach a higher dose".

I really should write up a quick guide for insurance, or maybe do a thread for questions and answers.
  • 0

#19 Anna

Anna

    Would-be Neurologist

  • Members
  • PipPipPip
  • 1,507 posts
  • Diagnoses:Bipolar I, most recent episode Mixed
  • Current Meds:Seroquel, Risperdal, Depakote, Provigil, Neurontin.
  • Location:Sunshine side. For now.

Posted 02 April 2010 - 04:50 AM

Do it, Serpens, that would be the SHIT.

This is where I am highly grateful for my cadillac insurance plan (I work for an Indian reservation as an in home therapist and they pay for EVERYTHING, and my kid was dx with asthma and allergies, sigh).

However, I have had some shitty insurance plans before, and here are some general rules:

If you are going for anything OUT OF the ordinary: e.g., unwillingness to split pills, non-generic (for whatever reason), strange lab tests (i.e., ones that are usually not considered "medically necessary")

FIRST read your insurance plan booklet, cover to cover. That really sucks to do, and is annoying.

THEN call an insurance rep. You don't HAVE to identify yourself, usually. If they ask you, that's fine.

ASK GENERAL questions, do not tell them what medication or test you are trying to get, but ask them things like "what do I do if I can't take generic" and shit like that.

GIVE the GENERAL information to your doctor, along with YOUR or HIS rational for doing this "out of the ordinary" thing.

THEN have doctor CALL the insurance company if he is willing to do so, and/or ask for a pharmacy override. You can do it the other way, if your like your pharmacist, they are generally the MOST savvy about trying to get insurance to pay for stuff, they do it all the time. They can direct you/and or call your doctor for you, and explain what the DOCTOR needs to say/write to the insurance company (I do love my pharmacist).

Usually, this process will get you what you need, in my experience. It's doing it in the right order, and the correct way, that counts.

You may still fail on some things, but then, insurance companies are trying to keep their costs down.

Anna
  • 0
Anna

Diagnosed Bipolar Type I, most recently Mixed.

Current Meds: Seroquel, Risperdal, Neurontin, Provigil.


0 user(s) are reading this topic

0 members, 0 guests, 0 anonymous users


Shirts to swipe from Crazymeds' Clothes Line See more ways to let my meds express your feelings at Straitjacket T-shirts. Shirts, hoodies & more, $15-$51.
Batshit Crazy shirt
Batshit Crazy
Mentally Interesting shirt
Mentally Interesting
Medicated For Your Protection shirt
Medicated For Your Protection
Breakfast of Champions shirt
Breakfast of Champions
Bipolar Is NOT Contagious shirts at Straitjacket T-shirts
Bipolar Is NOT Contagious
Also available for other brain cooties.


Keep Crazymeds on the air. Donate some spare electronic currency you have floating around The Cloud




Keep up with Crazymeds and and/or my slow descent into irreparable madness boring life. Pick your preferred social media target(s):
Follow Jerod Poore on Facebook
Wear my StraitjacketBatshit Crazy Blog
Crazymeds | Promote Your Page Too
Play Dress-Up with your Imaginary FriendsCrazymeds: The Blog