My wife has severe chronic pain, for which her pain management doctors have prescribed a high dose methadone regimen at more or less the same for the last 15 years.
We’ve had two doctors retire out from under us and after each time our insurance refused to authorize sale until we can get an additional note from her doctor verifying the dosage.
This last time, since she was almost out of her reserve supply, and the new doctor was hard to get hold of, we asked if it was possible to skip the insurance and just pay the whole cost out of pocket, and were told that that wasn’t an option. We tried to ask more about it but didn’t really get a straight answer, and didn’t want to spend to long at it since there were other people behind us waiting in line.
Any pharmacists out there on the Dope who can help to explain what the rules on this actually are? and how this would be different from our taking the prescription to a new pharmacy and claiming we didn’t have insurance.
IANA pharmacist, but methadone’s a controlled substance, and I’d almost guarantee the hoops you’re having to jump through are due to regulations trying to curb the opioid epidemic.
I don’t quite understand what you were asking for. If you have a prescription and you are insured, how would paying out of pocket solve the problem of an elusive doctor?
When you talk about an “additional note” verifying the dosage, do you believe that you hold a valid prescription, but this is an insurance-specific requirement?
I have been prescribed controlled substances where the doctor made some error in filling out the form, and the pharmacist told me it was causing the insurance to kick it back. So in a couple of cases, I asked what you did-- can I just pay for it? because in those cases where I asked, I knew it wouldn’t cost much. At that point I was told it wasn’t an insurance requirement, it was some kind of general requirement that would have caused a problem no matter what.
So why bother to drag the insurance company in, in the first place? Just to shift the blame? that only works if you don’t ask any more questions. I can’t believe so few people ask more questions that this gambit actually works. But it must work often enough that the counter people think it’s worth it.
IANA PharmD, but I used to work as a supervisor at a large prescription medication insurance company. Methadone is a medication that is going to be highly regulated on the doctor side (making sure your actually in need and proper medically necessary dosing), on the pharmacy side (making sure the med doesn’t interfere with other medications or that one isn’t getting multiple scripts from different doctors and filling them without one another’s knowledge), and on the insurance side (providing coverage if there’s an authorization and you don’t trip any insurance guidelines like refilling too early). No one of these entities wants to be liable for a methadone related problem with the patient or the FDA.
You mentioned she had a “reserve supply”…how? One reason why the pharmacist isn’t willing to fill might be because there is an inconsistency in her usage compared to what the prescription reads. Though each script may only be for a 30 day supply, the refill records with the pharmacy and the insurance company typically look back from 180-365 days. Two or three more a month over the course of that times can be a lot of extra medication being filled. Bottom line, if she needs more medication over a 30 day period than the script indicates (“every once in a while I take 2”) then talk to the doctor to see if the script can be amended. The pharmacist can then call the doc’s office to verify the change in therapy. The insurance is typically the LAST thing to be checked.
Another possibility is that the pharmacy is unwilling to sell controlled medications out of pocket because the insurance/medicare reimbursement for these is so ridiculously high. Plus, the cash payment for a controlled medication could be seen as a red flag by authorities even though the intent is benign.
Either way, get your doctor situation straight first. The pharmacy and insurance will fall in line after provided the therapy checks out.
I can think of a few reasons why a pharmacy might want to speak to a new doctor about the prescription but I’d be surprised if the insurance company knew what doctor wrote a particular prescription. They might want additional information to authorize a prescription , however, that usually happens when a drug is first prescribed.
The business about paying out of pocket may be a completely separate issue.
There’s a issue with pharmacy benefit managers ( the middlemen between your insurance company and your pharmacy) imposing gag orders and clawbacks as a condition of being a participating pharmacy. Lets say you have a prescription for Drug A. Your copay is $20 , but the retail cost w/o insurance is $5. Depending on the PBM they may , as a condition of being part of the network
require the pharmacist to collect $20 from you
require the pharmacy to remit the $15 difference between what you paid and the retail price
prohibit the pharmacy from telling you that it is cheaper not to use your insurance.
prohibit the pharmacy from not running it through your insurance
(Pharmacist here) All of the above, and the pharmacy may have a “no cash for controlled substances” policy for which they must not make exceptions, or potentially lose their job.
I’m guessing that you went to one of several large nationwide chains that have implemented policies like this; you can PM me the name of the store if you don’t want to post it here.
If I could add a question, I am doubly confused here. I thought the whole point of methadone was that it stops the cravings but you can’t get high off of it? So why is it even on the controlled schedule?
Methadone is still an opioid medication that has morphine-like pain reducing qualities. The linked wiki is pretty informative as to why it’s used to treat heroin addition.
Yeah, methadone is a drug of abuse too. So is buprenorphine (suboxone). They just give less euphoria than heroin and oxycodone and most other opioids. And they then tend to block the effects of those drugs too, though that blockade can be over-ridden.
The regulations behind methadone maintenance are complex and labyrinthine. It takes a special permit for a doctor to prescribe it to maintain or treat an addiction, though physicians who hold a standard DEA number can prescribe it for pain.
I’m done with prescribing it. I never did use it for treating addiction, but used to use it for chronic pain patients. But the pharmacodynamics are complicated, and overdosing on it is far too easy. A high proportion of opioid deaths are from methadone (or used to be, anyway until fentanyl started showing up in ‘heroin’). And a few of my patients diverted it, and I don’t need those headaches.
I still prescribe buprenorphine (which takes a special DEA license), but mainly to detox folks. I only maintain an addiction in pregnant women; one does not want to detox them until after baby is born, when baby can be detoxed separately.
A guy once told me that methadone is far harder to kick–as maintenance or addiction, take your pick–or more dangerous and needing closer monitoring, than heroin itself. As is alcohol also, I believe.
Heroin withdrawals are more intense, but over sooner. Methadone withdrawal is less intense but can last for weeks. Neither is particularly dangerous. Just miserable.
Withdrawal from alcohol and barbiturates can be fatal.
It seems likely to me that the pharmacy has the same policy as the insurance company, that they won’t fill a prescription for a controlled substance without verifying it with the doctor. Since the prescribing doctor has retired, they won’t fill it until your new doctor OKs it.
Methadone is supposed to block the high one normally gets from opiates, but it is an addictive pain killer. The potential for abuse is there even without the high.
Huh. Just to close this up, anti-anxiolytics (which for a short time I was taking low doses fairly regularly): how bad is getting off of them for truly habituated users?
I know this is a hijack, but it does touch on OP, unlike the -azapams/anti-anxiolytics, which go like a breeze through the pharmacist and cost pennies with insurance. The Ritalin-and-its-cousins I take (“like methamphetamine but different!”)–oy, what a headache for the slightest change in regimen, supplier, prescriber, whatever.
Several pharmacists and at least one doctor have replied, but I’m gonna toss in my two cents as well.
My first thought was that it’s a high dosage, so they want to call the doctor just to make sure you didn’t ‘adjust’ it. A 10 is easy to change into a 40. Back in the day, when I started taking Adderall (this was in the 90’s) my psych, IMO, over prescribed it. IIRC, she wanted me to take it either 3 or 4 times a day, so I was getting either 90 or 120 pills at a shot. Most of the Walgreen’s wouldn’t even have that many in stock. I’d typically have to stop back in a few days. About half the time they’d have to call the doc to verify it.
Additionally, you mentioned that the insurance company wanted a note from the doctor. In that case, assuming they were being straight with you, it’s the insurance company causing the hold up, not the pharmacy/pharmacist. It’s not uncommon for insurance companies to require a few things to happen before they’ll be okay with a certain drug (ie start with smaller doses or show that other meds haven’t worked), but in most cases a call from your doc can bypass all that.
My suggestion is to try GoodRx. Go to GoodRx dot com, search for your med (make sure the dosage and amount is correct) and it’ll list a bunch of pharmacies in your area and what you’ll get charged at each one. Click on yours and it’ll give you info to show the pharmacist. Ask them to use that instead of your insurance, it’ll probably be cheaper to. Tip: I typically do this beforehand and screenshot it. It’s just easier then screwing around when you’re at the counter trying to pull it up after you lost it.
The prescription is valid. The pharmacy is saying that the insurance won’t cover more than x pills in y days unless the doctor contacts them. So we are thinking that if its just an insurance requirement, paying out of pocket would get us this month’s prescription filled today rather than having to wait for the doctor to OK it so we could go through the insurance.
OK that makes some sense and at least we know that we aren’t the only one.
There has been no change in therapy, in a number of years and we get our perscriptions filled pretty much like clockwork. The reserve comes from occasional days where she for one reason or another doesn’t take the full dose, such as sleeps through it due to her chronic fatigue, or is having a particularly good day and forgets to take it. Then she puts that pill aside literally for a rainy day. We once had a hurricane hit on a day she was supposed to have a pain management appointment, and it took another two and a half weeks to fit her in. She rationed her pills to last but it was not a fun time for her. So she tries to have some set aside in case something like this happens again.
I’m going to guess that’s because benzos are C IV while the amphetamine type drugs are C II.
FWIW, I’ve never had a problem getting them filled. Change the drug, dosage etc, no one (at my Walgreens) has ever batted an eye, I even have them swap the insurance from my normal one to GoodRx and it knocks about $25 off the cost.
OK, the doc has to call in to your insurance provider and get a prior authorization to override the quantity limits imposed. Usually it’s just a form they fill out and fax back. Once it’s on file your pharmacy can run the claim and it will go through easy peasy.
Benzodiazepine withdrawal (valium, xanax, etc.) can be pretty nasty, and can involve withdrawal seizures which are on occasion fatal. The withdrawal is almost as miserable as opioid withdrawal, and may last for up to two weeks. But it’s not quite as dangerous as the aforementioned alcohol withdrawal, which have much higher fatality rates than the benzos. Without medical intervention, alcohol withdrawal can have a fatality rate of about 20%. Benzo withdrawal without treatment is around 1-2%, if that.
