Help with Appeal/Prescriptions!

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JulietteSuzanne
Regular Member


Date Joined Dec 2007
Total Posts : 104
   Posted 12/31/2008 8:29 AM (GMT -7)   
I am on my 2nd Appeal with my insurance. My doctor prescribed 120mg of Cymbalta (60mg 2X/day) for my Atypical Trigeminal Neuralgia. He gave me about a month supply of free samples, so I had enough for a while.

Low and behold, the pills decreased my face pain to almost nothing, whereas before, it was a constant, chronic burning, aching, nervy pain like I had an exposed root in my tooth. I have had this pain since 1999.

On the 120mg of Cymbalta, I didn't even have to take Vicodin throughout the day! Vicodin only gave me a very small amount of relief and sometimes did nothing for the pain.

I sent in the prescription through my mail order insurance plan. I get a letter indicating that they denied me the 120mg and can only pay for up to 60 mg. a day. I tried the 60mg. a day and the pain still broke though. So I went through the whole appeal process and am in severe pain and now looking for other options if they deny the 2nd appeal.

They don't care that I didn't have to take Vicodin AT ALL for the month while I was on Cymbalta. It worked that well for me!

They declined me in letter because "there were no studies indicating that Cymbalta in that amount was effective in relieving Trigeminal Neuralgia pain"

But I worked for ME!!

Does anyone have any suggestions for round two of my appeal? My husband is also suggesting that during the appeal process that we fill the prescription from a reputable Canadian or other off-shore pharmacy. Does anyone have any experience with off-shore pharmacies, reviews, or recommendations?

Please, any advice on appeals, insurance, or over-seas pharmacies would be greatly appreciated.

ekkorose
Regular Member


Date Joined Jul 2008
Total Posts : 329
   Posted 12/31/2008 8:34 AM (GMT -7)   
Wow. Have you had your doctor write a letter to the ins. company? Sometimes this helps with the appeal process. Also, have you contacted the makers to see if you can get on a plan since your ins. may not cover it.

That is all I can think of for now but other will be along to help as well. Maybe together we can figureo out a few good options for you.

Hysterectomy at 25

4 laproscopic surgeries since 24

Cervical stenosis in C3 & C4

_____________________________________________

 

Meds - percocet  3x day : nexium : xanax :

Supplements : calcium : magenesium :potassium : milk thistle : fish oil : B complex : vit E

____________________________________________

In the United States today, there is a pervasive tendency to treat children as adults, and adults as children. The options of children are thus steadily expanded, while those of adults are progressively constricted. The result is unruly children and childish adults. ~Thomas Szasz 


hurtzallot
Regular Member


Date Joined Nov 2008
Total Posts : 30
   Posted 12/31/2008 10:14 AM (GMT -7)   

It is my opinion that they are denying you due to new abstract clinical studies compiled by the FDA that contradict your assertions. You need to google Cymbalta and you will find, I believe, their basis for your denial in the recall on specific assertions and applications made by the makers of this medication.

By no means am I saying it doesn't work wonders for you, but it's my opinion this is the legality issue and a weak reason for your current situation. (It's effectiveness)


Disabled individual learning to live life again no matter what chronic pain or other obstacles stand in the way. Opinionated and you no what they say about opinions. Yesterday is history, tomorrow is not guaranteed, and today is a gift, that's why it's called the "Present."


JulietteSuzanne
Regular Member


Date Joined Dec 2007
Total Posts : 104
   Posted 12/31/2008 11:43 AM (GMT -7)   
Yes, my doctor is the one who wrote the letter stating that 120mg was working for me and in the letter, listed many other medicines that I have taken that were unsuccessful in alleviating my symptoms.

We did look on the Cymbalta/Lilly website and we don't qualify for the prescription plan due to income base.

I know the legal ramifications of all meds is a constant threat to the drug makers. The denial letter stated exactly where they based their decision on (which was based on what hurtzallot) is referring to. I also remember reading that it has withdrawn an application for stating that it can cure "chronic pain" (kinda like Neurontin was the cure all) because their patent is in the renewal process within the next year. Lilly also sued India for trying to copy the pill or something. It's all just too much for me.

Thanks for the info and help!

hurtzallot
Regular Member


Date Joined Nov 2008
Total Posts : 30
   Posted 12/31/2008 12:01 PM (GMT -7)   

ElenRigby,

There is hope for you though they have, this is my understanding, reapplied for it's usage and application in addressing those in chronic pain to take affect in 2009? Exact date I'm not sure of, but Elli Lilly has the money to find many more of those, like yourself who benefit greatly from it and it will be allowed to be marketed as such. Too bad they can't rush it through for your sake, it's a sad shame. I have never heard of the FDA getting a speeding ticket. Get Well Soon.

hurtzallot eyes

 

Disabled individual learning to live life again no matter what chronic pain or other obstacles stand in the way. Opinionated and you no what they say about opinions. Yesterday is history, tomorrow is not guaranteed, and today is a gift, that's why it's called the "Present."


PAlady
Veteran Member


Date Joined Nov 2007
Total Posts : 6795
   Posted 12/31/2008 12:34 PM (GMT -7)   
Elenor,
It's so unfair isn't it? Such a Catch 22. We have a tough time getting opiods, yet you fiind something that allows you to both reduce your opiod dependence and improves your pain and you run into the technical snags.

I had research cymbalta because I was on it briefly and it was great except it affected my seizure threshold so I had to stop it (i also have a seizure disorder). I know the 60 mg is considered the max effectivenes threshold, but I have no doubt that you needed the 120 to get your results. I wonder about some type of dispensation from the FDA, although that won't be quick and easy either.

I really can't advise you to use off shore pharmacies, etc., as it's probably illegal unless you're doing it with your doctor's prescription. I may not have read all your posts accurately, but could you private pay for the medication? I know it's expensive, but with your doctor's prescription if you're private paying that's not illegal. Are there any clinical trials you could be involved with?

I don't know how close to Canada that you live, but it may not be illegal to go to a reputable Canadian pharmacy if you have a doctor's prescription. But I'd be very leary of any mail order or overseas pharmacies, even with a doctor's Rx. This is a relatively new med, and I'd wonder what I was getting. I live a couple of hours from Canada and actually do know people who go across the border to get their meds because it's less expensive. I think they take their doctor's scripts so I don't think this is illegal.

PaLady

ekkorose
Regular Member


Date Joined Jul 2008
Total Posts : 329
   Posted 12/31/2008 5:21 PM (GMT -7)   
On top of what PaLady said, if you cannot pay for the whole thing out of pocket, could you do half by insurance and half out of pocket?

Hysterectomy at 25

4 laproscopic surgeries since 24

Cervical stenosis in C3 & C4

_____________________________________________

 

Meds - percocet  3x day : nexium : xanax :

Supplements : calcium : magenesium :potassium : milk thistle : fish oil : B complex : vit E

____________________________________________

In the United States today, there is a pervasive tendency to treat children as adults, and adults as children. The options of children are thus steadily expanded, while those of adults are progressively constricted. The result is unruly children and childish adults. ~Thomas Szasz 


PAlady
Veteran Member


Date Joined Nov 2007
Total Posts : 6795
   Posted 12/31/2008 5:54 PM (GMT -7)   
I wondered about that, too, ekkrose. Wonder if insurance would give you a hard time. Would you doctor be able to help out with samples or coupons, especially if you're one of only a few of his/her patients who needs the 120mg to get relief. Just trying to brainstorm a little for you. Hope I'm not making things worse!

PaLady

skeye
Veteran Member


Date Joined Mar 2008
Total Posts : 2976
   Posted 12/31/2008 8:46 PM (GMT -7)   
Hi ElenorRigby,

Have you asked your doc for more free samples? Maybe you can have your insurance pay for 60mg & get the rest from you doctor. A lot of doctors will do this sort of thing for their patients, as long as they have the samples (especially if they know of your circumstance). I was on cymbalta for a while last year & I was also at the point of taking 120mg a day (although, it unfortunately didn't help me at all). I don't think I ever put 120mg through to my insurance company because I used both prescription cymbalta & samples, but I know that they accepted 90mg (a script for 60 & a script for 30 each taken once a day for a total of 90mg/day). Maybe your insurance company would accept that much? I am surprised that they didn't accept the 120mg because Cymbalta has been advertised for depression & pain for a while & my PM told me that 90 - 120mg was the dosaged used to treat pain, whereas up to 60mg was the dosage used to treat depression.

Good luck! I hope you can find some compromise!

Skeye

JulietteSuzanne
Regular Member


Date Joined Dec 2007
Total Posts : 104
   Posted 12/31/2008 11:15 PM (GMT -7)   
Thanks so much for these suggestions everyone!

(skeye) I might ask my doctor on the 9th if he could write it in a different way that implicitly stated that it was for PAIN and not depression. Thanks for that suggestion.

(PAlady) The Canadian presciption---it would be out of pocket money through my doctor's written prescription. I have no idea if that is illegal or not? I wouldn't think so since it is a presciption and I'm paying out of pocket for it. I'm simply resorting to that if my insurance wont pay from the 2nd appeal. Cymbalta is waaay less expensive in Canada than here in the US.

One thing is...my doc is very good with samples, but for such a lengthy period (until the med quits working lol) I don't know.

And yep---that is what makes my blood boil...we pay loads of money for insurance, it works, my doctor is prescribing it, it's not anything narcotic or an opiod etc. It should be the simplest thing in the world. But BAM...when I finally find something that relieves my pain, life (insurance/big business) throws me a curve ball. So very frustrating.

I'll let ya'll know the outcome of my appt. next Thurs. Ya'll be safe, healthy, happy, and have a wonderful new year!

Tirzah
Veteran Member


Date Joined Jul 2008
Total Posts : 2280
   Posted 1/1/2009 12:15 PM (GMT -7)   
This site covers the legality of importing from Canada. It looks like since Cymbalta is manufactured in Indiana that it is considered illegal to import them.

http://www.fda.gov/importeddrugs/

Good luck with your appeal. At least the good news is that it looks like Cymbalta will go generic next year so perhaps there is hope yet for the future.

kttn251977
Veteran Member


Date Joined Jul 2007
Total Posts : 554
   Posted 1/1/2009 3:31 PM (GMT -7)   
See if your Dr can call the people who deal with your medical & say that the product is "medically necessary". Sometimes those 2 words from your Dr will open up a whole new variety of things you couldn't use before. Use those words exactly. Your Dr will know what it means, if not tell him you can't get it & to get enough samples from the pharm rep the next time they come in so you can get what you need. I know its working well with Lyrica to help against my fibro. pain. Good luck.
RX's: Oxycontin 80 MG 2x's daily; Dilaudid 8 MG 4xs daily; Zanaflex 4mg 3x's daily; Restoril 15mg 1x; Soma 3x's daily; Lyrica 100 MG 3x's daily (pain & fibro.); Phenergan 25 MG (as needed); Amitriptyline 25 MG 1x (chronic pain); Cymbalta 60mg 2x's daily (pain from fibro); Metoclopram (as needed) & Senokot (as needed).
"The most critical choice you'll ever make is the one you make about what you're going to do with this. The past is over. The future hasn't happened yet. The only time is now."
- Dr. Phil


Chartreux
Veteran Member


Date Joined Aug 2006
Total Posts : 9622
   Posted 1/1/2009 3:54 PM (GMT -7)   
I would agree with Skeye as getting your Doctor to maybe giving it for treatment of depression
instead of for pain. Sure hope this info helps...
Keep us posted, okay
Lots of soft hugz.......
**********************************************
* Asthma, Allergies, Osteoarthritis, Spinal Stenosis, Degenative Disc, Fibromyalgia, Gerd, Enlarged Pituitary Gland
******** "We could never learn to be brave and patient if there were only joy in the world" from Helen Keller *********

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JulietteSuzanne
Regular Member


Date Joined Dec 2007
Total Posts : 104
   Posted 1/1/2009 11:13 PM (GMT -7)   
Thanks a million everyone who replied. My husband and I now, thanks to ya'll, have an arsenal of information and suggestions to help me on my path to some better relief when I go to my doctor about this next week!

Hugs and kisses and prayers to everyone on this wonderful site!
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