Need advice!! Insurance wants me to try other med!!!!!

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s.a.s
New Member


Date Joined Oct 2008
Total Posts : 5
   Posted 12/30/2008 6:36 PM (GMT -7)   
Hey everyone!!
I have been taking samples of Cymbalta for awhile now. Paxil wasn't working for my anxiety so doc started me on the Cymbalta.  Now my insurance is saying they won't cover it because I need to have two failed meds. The problem is that I have finally gotten used to the Cymbalta and am happy with it.  I actually stood in the middle of a store for about a half hour ordering something and didn't freak out :)  This is the list they want me to pick from so I would like opinions on any of them or if someone knows of a way I can fight my insurance company to stay on Cymbalta please, please fill me in!!
Cymbalta would be about $157 a month out of my pocket which at this point I'm thinking it's worth it even if I have to pick up another job!!
Also.... do docs know that the newer meds aren't covered before they hand out samples??
 
Celexa
fluvoxamine
Prozac
Zoloft
Paxil
Effexor
 
Only dealing with general anxiety and social anxiety not depression.
 
Thanks guys,
 
s.a.s

Green Grove
Veteran Member


Date Joined Oct 2008
Total Posts : 2424
   Posted 12/30/2008 6:56 PM (GMT -7)   
Hi S.A.S.

Nice to meet you and welcome to the A/P Forum!

As far as your insurance company goes (and let me guess that you live in America), there is not much to do except appeal according to their rules and regs. If it is something really drastic, you can always file a complaint with the company. It is really crazy that you have to go through this and all I can say is that I pray President Elect Obama will have the time to make good on his promise to us. . . considering the mess he has to work with.

Good luck to you! Somebody else will be on here with better advice I'm sure :)
Much Love, Hugs, Peace and Comfort!!!
Your Bro,
Sam
   
"Don't sweat the petty things and don't pet the sweaty things :)"
~George Carlin~
 
Not a medical professional.  Seek your physician's advice
before making changes to your meds or lifestyle :)


Aries8
Veteran Member


Date Joined Dec 2008
Total Posts : 1015
   Posted 12/30/2008 7:03 PM (GMT -7)   
Ask your physician if he knows that Cymbalta is not covered under your insurance. You can complain to him through his office. I would.
Secondly, find out which covered med is the closest to Cymbalta. That way, maybe the transition won't be as bad.
I take Prozac. The side effects at first were dizziness and my anxiety was a little worse. The side effects went away after a few weeks. Side effects are different for everyone, as you know. I've read what other people are taking on this forum, and they all seem happy with what they're taking. I'm sure you can find one that will make you happy, too.
I'm so sorry that you have to go through this mess! Let us know what happens!

FitzyK23
Veteran Member


Date Joined May 2005
Total Posts : 4219
   Posted 12/30/2008 7:34 PM (GMT -7)   
First have you ever in your life taken any of the other meds? If so your doc can say they didn't work for you. Most insurance companies have a medical necessity exception. Your doc could write a letter that it would endanger your health to stop the Cymbalta at this time.
27 Year old married female law student (last year!!). Diagnosed w/ CD 4 years ago, IBS for over 10 years before that, which was probably the CD. I am sort of lactose intollerant too but can handle anything cultured and do well w/ lactose pills and lactaid. For crohns I am currently on Pentasa 4 pills/4x day and hysociamine prn. I also have bad acid reflux and have been on PPI's since age 13. I have been through prilosec, prevacid, and nexium. Currently I am on Protonix in the morning and Zantac at night. I also take a birth control pill to allow some fun in my life.


Tirzah
Veteran Member


Date Joined Jul 2008
Total Posts : 2282
   Posted 12/30/2008 7:44 PM (GMT -7)   
S-
Couple of ideas:
Ask your doctor to write a letter to the insurance company explaining why there is no good alternative for you to switch to. Sometimes the insurance companies will weigh that information & have an independent medical reviewer consider whether to make an exception for a particular patient and cover the medication without you having to follow their standard guidelines.

If that doesn't work, you could see whether the insurance company will pay the contracted amount for one of those other medications so you only have to pay the difference.

It's pretty unfortunate that your doc started you on a med that now might not be covered, but every plan is different. Even within the same insurance provider, there are different contracted services and what is covered changes regularly. Cymbalta is covered by a lot of insurers (mine, for example), but certainly not all. The only way to really prevent something like that from happening again is to check with your prescription insurer ahead of time as to whether or not they will cover a particular drug. The other thing to consider is that some medications will be covered for one diagnosis, but not another. Anxiety is an off-label use of Cymbalta (on-label for depression & chronic pain) so that makes it more likely the insurer will deny coverage.

Also, I'm not sure about Cymbalta in particular but a fair amount of drug companies will give coupons for self-pay patients in exchange for feedback, joining a focus group, answering periodic surveys, etc. It won't cover the entire cost but maybe could help some. If there's nothing on their site, try emailing a sappy letter to the manufacturer about how Cymbalta has changed your life & you just wish either that your insurance would cover it or that it wasn't so expensive and if there are ever any coupons or special offers you would really appreciate being notified.

Green Grove
Veteran Member


Date Joined Oct 2008
Total Posts : 2424
   Posted 12/30/2008 9:31 PM (GMT -7)   
Told you that you would get some better advice :) lol Thanks you all for educating me too :)
Much Love, Hugs, Peace and Comfort!!!
Your Bro,
Sam
   
"Don't sweat the petty things and don't pet the sweaty things :)"
~George Carlin~
 
Not a medical professional.  Seek your physician's advice
before making changes to your meds or lifestyle :)


Shia
Regular Member


Date Joined Dec 2008
Total Posts : 80
   Posted 12/31/2008 12:45 AM (GMT -7)   
SAS, I feel your pain :( Insurance companies are hard to deal with. You're saying you need two fail med's before your insurance can cover it? Is there a way you can make a "deal" with your doctor. I know it's wrong but it is not fair. Or maybe have someone who has medicare to get the medications under their name?
I have my friend pick up mine because I have no insurance at all... And it would cost me around 100 dollar a month and I have no income I am no documented...
Anyways, I know it's wrong but sometimes these insurance companies are very unfair

Hibee
Forum Moderator


Date Joined Oct 2008
Total Posts : 6492
   Posted 12/31/2008 3:43 AM (GMT -7)   
Hi SAS

I feel for you you have had some great advice re dealing with the insurance company, i cant comment on this as i live in the uk so its different over here. In regards to the medications i have taken Celexa and prozac which are both SSRI, Celexa is regarded as a good choice to treat anxiety but every one is different and what works for one person may not work for an othe so i would speak to your doctor. I currently take Effexor which is an SNRI and is in the same class as Cymbalta these are newer forms of antidepressants which are said to have good results with people who have not had much joy with the other types of antidepressants.

I hope you sort out your medication soon take care.

Georgie Girl
Regular Member


Date Joined May 2008
Total Posts : 319
   Posted 12/31/2008 5:28 AM (GMT -7)   

My insurance company covers Cymbalta.

But is doesn't cover Lexapro.  It says Celexa is just as good and it is covered.  My pdoc says that Lexapro is more effective for anxiety and it isn't the same at all.  Still, I take the Celexa since the insurance company refuses to cover Lexapro. 

Since there are so many insurance companies and their coverage is all different, there is no way for my pdoc to know ahead of time what medications won't be covered. 

 


Georgie Girl

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