Apparently, this is something new that the Feds/CMS has implemented with Medicare Part D and Medicare -C ( Advantage). According to this article, it appears that the various PBM ( Prescription Benefit Managers) have not done much in educating Pharmacists/Pharmacies on how this is supposed to be handled in the billing of the pt’s prescriptions to the PBM on the pharmacy computer system.  According to the article the PBM’s customer service staff was not well trained either with the exception of training the CS staff to use this opportunity with the pt to try to get the pt to switch their Rxs to the PBM’s mail-order pharmacy. A quote from Obama’s first chief of staff seems to apply here “You never want a serious crisis to go to waste. And what I mean by that [is] it’s an opportunity to do things that you think you could not before”

what is MPPP in the Medicare Part D program?

Citations:

1. https://www.lung.org/getmedia/d10aa01a-efcc-4daf-88e2-5bb2298574a5/MedicarePrescriptionPaymentPlan_Infographic.pdf
2. https://targethiv.org/library/faqs-medicare-prescription-payment-plan
3. https://www.lung.org/policy-advocacy/healthcare-lung-disease/healthcare-policy/medicare/prescription
4. https://www.mintz.com/insights-center/viewpoints/2146/2025-02-13-operationalizing-medicare-prescription-payment-plan-and
5. https://avalere.com/insights/navigating-the-medicare-prescription-payment-plan-what-it-means-for-patients-and-patient-groups
6. https://www.lls.org/article/get-informed-important-changes-medicare-part-d
7. https://www.medicarerights.org/medicare-watch/2024/07/25/guidance-on-inflation-reduction-acts-medicare-prescription-payment-plan-released
8. https://www.lungevity.org/blogs/what-you-need-to-know-about-changes-to-medicare-part-d-in-2025
9. https://www.sanfordhealthplan.com/align/pharmacy-and-drug-coverage/medicare-prescription-payment-plan
10. https://www.panfoundation.org/understanding-the-medicare-prescription-payment-plan/
11. https://www.cms.gov/inflation-reduction-act-and-medicare/part-d-improvements/medicare-prescription-payment-plan
12. https://www.medicare.gov/prescription-payment-plan
13. https://www.medicare.gov/publications/12211-whats-the-medicare-prescription-payment-plan.pdf
14. https://www.cms.gov/files/document/faqs-related-medicare-prescription-payment-plan.pdf
15. https://www.humana.com/pharmacy/patient-assistance/medicare-prescription-payment-plan
16. https://www.medicare.gov/prescription-payment-plan/before-payment-option
17. https://avalere.com/insights/navigating-the-medicare-prescription-payment-plan-what-it-means-for-part-d-plan-sponsors

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Answer from Perplexity: pplx.ai/share

PBMs warn of low compliance for Part D claims with certain MPPP BIN/PCNs

https://ncpa.org/newsroom/qam/2025/02/20/pbms-warn-low-compliance-part-d-claims-certain-mppp-binpcns

Filed under: General Problems | Leave a Comment »

This is going to be a fairly long post, I intend to make a post to @DOGE on “X” about what most chronic pain pts would agree is a TEN BILLION DOLLAR waste of money. But all of this information is TOO LONG to fit in a single post on “X”. If you are a pt that your pain doc is telling you… no Rx for pain meds unless you submit to ESI (Epidural Spinal Inj). They can only charge $100-$200 for an office visit for prescribing oral pain meds but giving you ESI – according to this information – will generate ~ $4,000 for the practice. Another sign that healthcare is nothing more, nothing less than a FOR PROFIT BUSINESS.

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Those $$ seem quite low – my question was for specifically epidural SPINAL injection, the $$$ that you stated was probably for general IM injections of corticosteroid – like depo-medrol

You’re correct, and I apologize for the confusion in my previous response. Let me provide more accurate information specifically for epidural spinal injections of corticosteroids:

## Cost of Epidural Spinal Injections

The cost of epidural spinal injections for corticosteroids is indeed higher than general intramuscular injections. Here’s a more accurate breakdown:

– **Average Cost per Injection**: Approximately $1,000 in 2025[1].

– **Total Cost for Multiple Sessions**: Around $4,000 or more, as multiple injections are often necessary[1].

## Factors Affecting Cost

Several factors can influence the cost of epidural spinal injections:

1. **Location**: Costs can vary depending on where you live and where the procedure is performed (e.g., doctor’s office vs. hospital)[1].

2. **Insurance Coverage**: For patients with insurance, including Medicare, out-of-pocket costs may be lower[3].

3. **Number of Injections**: Multiple sessions are often required, which increases the overall cost[1].

4. **Additional Services**: The total cost may include the office visit, medical imaging (such as X-rays or CT scans), and the procedure itself[1].

## Medicare Billing

It’s worth noting that Medicare has specific guidelines for covering epidural steroid injections:

– Medicare improperly paid physicians $3.6 million for epidural steroid injection sessions that exceeded coverage limitations during a two-year audit period from 2019 to 2020[2].

– Medicare limits epidural steroid injections to a maximum of four sessions per spinal region during any 12 months[3].

## Billing Codes

The most common CPT codes for epidural steroid injections are:

– 62320-62323: Injection of diagnostic or therapeutic agent, interlaminar epidural or subarachnoid[5].
– 64479-64484: Injection of anesthetic agent and/or steroid, transforaminal epidural[5].

In conclusion, the cost of epidural spinal injections for corticosteroids is significantly higher than general intramuscular injections, with an average cost of around $1,000 per injection and potentially $4,000 or more for a full course of treatment.

Citations:
[1] https://expresslegalfunding.com/epidural-steroid-injections-cost/
[2] https://oig.hhs.gov/reports/all/2023/medicare-improperly-paid-physicians-for-epidural-steroid-injection-sessions/
[3] https://scottglovsky.com/insurance-bad-faith/health-claim-denial/steroid-injections/
[4] https://www.oregon.gov/oha/HPA/DSI-HERC/EvidenceBasedReports/CG-Low-Back-Pain-Corticosteroid-Injections-4-20-17.pdf
[5] https://www.hcfraudshield.com/spinal-injection-pain-in-the-neck/
[6] https://www.healthnote.com/ensuring-accurate-billing-and-documentation-for-lumbar-epidural-steroid-injections/
[7] https://emedicine.medscape.com/article/325733-overview
[8] https://guidelines.carelonmedicalbenefitsmanagement.com/interventional-pain-management-2024-06-30/
[9] https://sesamecare.com/blog/how-much-does-a-cortisone-injection-cost
[10] https://www.acpjournals.org/doi/10.7326/M15-0934
[11] https://www.caresource.com/documents/marketplace-ky-policy-reimburse-py-1051-20191218.pdf
[12] https://www.paintreatmentspecialists.com/does-insurance-cover-back-pain-injections/
[13] https://www.anesthesiallc.com/publications/anesthesia-provider-news-ealerts/1464-special-alert-anesthesia-for-epidural-steroid-injections-in-jeopardy
[14] https://pubmed.ncbi.nlm.nih.gov/23953016/
[15] https://cost.sidecarhealth.com/ts/epidural-steroid-injection-cost-by-state
[16] https://www.medicare.gov/procedure-price-lookup/cost/64483/
[17] https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/wa/Medicaid/resource/mcp/MCP-032-Epidural-Steroid-Injections-for-Chronic-Back-Pain.pdf
[18] https://cost.sidecarhealth.com/n/epidural-steroid-injection-cost
[19] https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=39054&ver=11
[20] http://mcgs.bcbsfl.com/MCG?mcgId=02-61000-31&pv=false
[21] https://www.desertspineandsports.com/cash-pricing/
[22] https://www.medicare.gov/procedure-price-lookup/cost/62287
[23] https://www.molinahealthcare.com/providers/sc/medicaid/PDF/Epidural-Steroid-Injections-for-Chronic-Back-Pain-MCG-032.pdf
[24] https://www.ohsu.edu/sites/default/files/2019-04/Epidural-Steroid-Injections-Medications-and-Dosages.pdf
[25] https://pmc.ncbi.nlm.nih.gov/articles/PMC7145384/
[26] https://hssh.health/blog/15-types-of-injections-for-back-pain/
[27] https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=58777&ver=11
[28] https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=abk1059
[29] https://www.osc-ortho.com/blog/debunking-myths-about-epidural-steroid-injections-esis-in-the-lumbar-spine/
[30] https://www.aetna.com/cpb/medical/data/1_99/0016.html
[31] https://caringmedical.com/prolotherapy-news/epidural-steroid-injections/
[32] https://www.prolianceorthopedicassociates.com/spinal-injections-what-you-need-to-know
[33] https://pmc.ncbi.nlm.nih.gov/articles/PMC4410617/
[34] https://www.aapc.com/discuss/threads/is-an-in-office-injection-considered-prescription-drug-management.191241/
[35] https://www.nhs.uk/conditions/steroid-injections/
[36] https://www.palmettogba.com/palmetto/jjb.nsf/DID/SSLAIT1XNR
[37] https://www.caresource.com/documents/marketplace-ga-policy-reimburse-py-1127-20200626
[38] https://asipp.org/wp-content/uploads/Table-1.-2022-Physician-Proposed-Payment-Rates.pdf
[39] https://pmc.ncbi.nlm.nih.gov/articles/PMC8360670/

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Answer from Perplexity: pplx.ai/share

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Can you determine the gross $$ per year for epidural spinal injections of corticosteroid

Based on the search results, we can calculate the gross revenue per year for epidural spinal injections of corticosteroids:

## Calculation

– Number of injections per year: 10 million[3][5]
– Average cost per injection: $1,000

Gross revenue = Number of injections × Average cost per injection
$$ 10,000,000 \times \$1,000 = \$10,000,000,000 $$

## Result

The gross revenue per year for epidural spinal injections of corticosteroids is approximately $10 billion.

## Additional Context

It’s important to note that:

1. This figure represents the total amount billed, not necessarily the amount paid out by insurance companies or patients.

2. The number of injections has been increasing over time. From 2000 to 2014, there was a 99% increase in overall epidural injections per 100,000 Medicare beneficiaries, with an annual increase of 5%[4].

3. Different types of epidural injections have shown varying trends. For example, lumbosacral transforaminal epidural injections increased by 609% from 2000 to 2014, with an annual increase of 15%[4].

4. Despite the high number of injections, there is ongoing scrutiny of this procedure due to its varying effectiveness and potential risks. The FDA has required label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections[2].

5. The effectiveness and safety of these injections continue to be subjects of research, with efforts being made to better identify patients who are most likely to benefit from the procedure[5].

Citations:
[1] https://www.painphysicianjournal.com/current/pdf?article=NzAyNg%3D%3D&journal=125
[2] https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-requires-label-changes-warn-rare-serious-neurologic-problems-after
[3] https://pmc.ncbi.nlm.nih.gov/articles/PMC7379698/
[4] https://pmc.ncbi.nlm.nih.gov/articles/PMC5168679/
[5] https://www.hopkinsmedicine.org/news/newsroom/news-releases/2023/02/rapid-screening-test-predicts-effectiveness-of-steroid-injections-for-neck-pain
[6] https://pmc.ncbi.nlm.nih.gov/articles/PMC9296573/
[7] https://my.clevelandclinic.org/health/treatments/22301-epidural-steroid-injection-esi
[8] https://www.ncbi.nlm.nih.gov/books/NBK537320/
[9] https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=39015&ver=12
[10] https://academic.oup.com/painmedicine/article-abstract/19/7/1299/5003355
[11] https://emedicine.medscape.com/article/325733-overview
[12] https://comprehensivespine.weillcornell.org/about-us/publications/transforaminal-epicural-steroid-injections/
[13] https://www.hss.edu/conditions_epidural-injections-faqs.asp
[14] https://cdn.ymaws.com/www.ipsismed.org/resource/resmgr/factfinder/factfinder_2019_06_annual_do.pdf
[15] https://my.clevelandclinic.org/health/treatments/22091-lumbar-epidural-steroid-injection
[16] https://www.westernreservehospital.org/blog/minimally-invasive-interventions-persistent-back-pain
[17] https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/690%20Epidural%20Steroid%20Injections%20for%20Neck%20and%20Back%20Pain%20prn.pdf
[18] https://academic.oup.com/painmedicine/article-abstract/20/10/2069/5555353
[19] https://hssh.health/blog/the-dark-side-of-epidural-steroid-injections-risks-complications/
[20] https://www.medcentral.com/pain/chronic/how-safe-epidural-steroid-injection-examining-drug-related

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Answer from Perplexity: pplx.ai/share

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Has the FDA approved corticosteroids be given via the ESI route

The FDA has not approved corticosteroids for epidural injection. This lack of approval has been consistently maintained despite the widespread use of epidural steroid injections (ESIs) for treating back and neck pain.

Key points regarding the FDA’s stance on corticosteroids for epidural use:

1. **No FDA Approval**: The FDA has not approved any corticosteroids for epidural administration[1][5][8].

2. **Safety Warning**: In April 2014, the FDA issued a warning about the risks associated with injecting corticosteroids into the epidural space[2][5].

3. **Label Changes**: The FDA required the addition of a warning to the drug labels of injectable corticosteroids to describe the risks associated with epidural use[5].

4. **Lack of Established Safety and Effectiveness**: The FDA has stated that the effectiveness and safety of corticosteroids for epidural use have not been established[1][4][5].

5. **Advisory Committee Meeting**: In November 2014, the FDA convened an Advisory Committee meeting to discuss the benefits and risks of epidural corticosteroid injections[4][8].

6. **Ongoing Use Despite Lack of Approval**: Despite the FDA’s position, ESIs have been widely used for decades, with numerous studies demonstrating their efficacy and safety in certain patient populations[6][8].

It’s important to note that while the FDA has not approved corticosteroids for epidural use, they continue to be commonly utilized in clinical practice for treating various spinal conditions. Patients should discuss the potential benefits and risks of ESIs with their healthcare providers, considering alternative treatment options as well.

Citations:
[1] https://pubmed.ncbi.nlm.nih.gov/25054397/
[2] https://jamanetwork.com/journals/jama/fullarticle/1874492
[3] https://www.providencehealthplan.com/-/media/providence/website/pdfs/providers/medical-policy-and-provider-information/medical-policies/mp14.pdf
[4] https://www.apsf.org/article/fda-issues-drug-safety-communication-about-epidural-corticosteroid-injections/
[5] https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-requires-label-changes-warn-rare-serious-neurologic-problems-after
[6] https://journals.lww.com/clinicalpain/fulltext/2021/09000/safety_of_epidural_steroid_injections_for.9.aspx
[7] https://www.medcentral.com/pain/chronic/how-safe-epidural-steroid-injection-examining-drug-related
[8] https://pmc.ncbi.nlm.nih.gov/articles/PMC8360670/
[9] https://dcoadmv.com/epidurals/
[10] https://www.fda.gov/media/184938/download
[11] https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/011757s119lbl.pdf
[12] https://www.drugs.com/news/do-steroid-shots-help-ease-back-pain-experts-weigh-123724.html
[13] https://rapm.bmj.com/content/46/3/203
[14] https://www.nature.com/articles/d43747-020-00194-1.pdf
[15] https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14804
[16] https://www.painphysicianjournal.com/current/pdf?article=MjEyMg%3D%3D&journal=83
[17] https://www.uhcprovider.com/content/dam/provider/docs/public/policies/oxford/epidural-steroid-facet-injections-spinal-pain-ohp.pdf
[18] https://www.painmedicineconsultants.com/blog/am-i-a-candidate-for-an-epidural-find-relief-from-chronic-pain
[19] https://www.fda.gov/drugs/safe-use-initiative/safe-use-initiative-completed-projects
[20] https://jamanetwork.com/journals/jama/fullarticle/2213785

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Answer from Perplexity: pplx.ai/share

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Does the pharma that makes Depo-medrol suggests that it be used in ESI

Pfizer, the manufacturer of Depo-Medrol (methylprednisolone acetate), explicitly advises against using the drug for epidural steroid injections (ESI). Here are the key points regarding Pfizer’s stance on Depo-Medrol for ESI:

1. **Not Recommended**: As early as 1995, Pfizer (then Pharmacia & Upjohn) stated in internal documents that they had received reports of severe medical events associated with epidural injections of Depo-Medrol[1].

2. **Package Insert Warning**: Pfizer initially included a warning in the package insert stating that “epidural administration of Depo-Medrol is NOT RECOMMENDED”[1].

3. **Contraindication in Some Countries**: In Australia and New Zealand, Pfizer has contraindicated Depo-Medrol for epidural administration. Their revised data sheet includes a Black-Box Warning stating: “Depo-Medrol MUST NOT be used by the epidural route” due to reports of “serious medical events”[2].

4. **US Labeling**: While the US labeling does not explicitly contraindicate epidural use, it does not recommend or approve it either. The US data sheet lists severe adverse events for both intrathecal and epidural routes of administration[2].

5. **FDA Stance**: The FDA has not approved any corticosteroids, including Depo-Medrol, for epidural administration[2][4].

6. **Off-Label Use**: Despite these warnings and lack of approval, Depo-Medrol continues to be widely used off-label for epidural injections to treat chronic neck and back pain[1][4].

7. **Recent Developments**: As of 2025, Pfizer’s official product information for Depo-Medrol does not include epidural administration in its list of approved routes of administration or indications[6].

In conclusion, Pfizer, the manufacturer of Depo-Medrol, does not suggest or endorse its use for epidural steroid injections. On the contrary, they have explicitly warned against this practice in some countries and have not sought FDA approval for this use in the United States.

Citations:
[1] https://www.bmj.com/rapid-response/2011/10/30/esis-depo-medrol-efficacy-amp-safety-issues
[2] https://downloads.regulations.gov/FDA-2013-N-1523-0007/attachment_1.pdf
[3] https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/011757s119lbl.pdf
[4] https://www.advisory.com/daily-briefing/2018/08/17/injection
[5] https://vancouverdisccenter.com/epidural-steroid-injections-are-the-risks-worth-the-benefits/
[6] https://www.medicines.org.uk/emc/product/8957/smpc
[7] https://labeling.pfizer.com/ShowLabeling.aspx?id=1120
[8] https://www.umms.org/rehab/health-services/pain-management/treatments/epidural-steroid-injections
[9] https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-requires-label-changes-warn-rare-serious-neurologic-problems-after
[10] https://www.hss.edu/conditions_epidural-injections-faqs.asp
[11] https://www.painphysicianjournal.com/current/pdf?article=MjEyMg%3D%3D&journal=83
[12] https://emedicine.medscape.com/article/325733-overview
[13] https://www.pfizermedicalinformation.com/depo-medrol-single-dose-vial/warnings
[14] https://jamanetwork.com/journals/jama/fullarticle/2213785
[15] https://pmc.ncbi.nlm.nih.gov/articles/PMC8360670/
[16] https://www.apsf.org/article/fda-issues-drug-safety-communication-about-epidural-corticosteroid-injections/
[17] https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/690%20Epidural%20Steroid%20Injections%20for%20Neck%20and%20Back%20Pain%20prn.pdf
[18] https://labeling.pfizer.com/showlabeling.aspx?id=550
[19] https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=36920
[20] https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/epidural-steroid-injections-spinal-pain.pdf

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Answer from Perplexity: pplx.ai/share

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are there any clinical studies that would indicate that injecting corticosteroids via the ESI route in the spine actually increase the deterioration of certain areas of the spine. Which could in the long term, cause the pt to have increased pain

Yes, there are clinical studies that suggest epidural steroid injections (ESIs) in the spine may lead to increased deterioration in certain areas and potentially cause long-term increased pain for patients. Here are the key findings:

## Negative Long-term Outcomes

A study published in 2013 found that patients with spinal stenosis who received ESIs had significantly less improvement at four years follow-up compared to those who did not receive ESIs[3]. This was true for both surgical and non-surgical patients:

– Surgical patients who had ESIs showed less improvement in physical functioning.
– Non-surgical patients who had ESIs experienced less improvement in both pain and functioning.

## Potential for Spinal Injury

ESIs can potentially cause further injury to the spine over time[2]:

– Repeated injections can weaken bones and increase the risk of fractures.
– ESIs may impair the spine’s ability to heal or regenerate tissue.
– The injections can mask or exacerbate underlying causes of back pain, such as poor posture or spinal misalignments.

## Lack of Long-term Benefits

A 2022 study on older adults with new episodes of back pain found that while patients treated with ESI showed long-term improvement, this improvement was unlikely to be a result of a specific ESI effect[6][7]. The study concluded that older adults with new episodes of back and leg pain are unlikely to experience long-term benefits from ESI.

## Increased Surgical Complexity

For patients who eventually require surgery, prior ESI treatment may complicate the procedure[3]:

– Surgery took about half an hour longer for patients who had received ESIs.
– ESI patients spent about one day longer in the hospital post-surgery.

## Masking Underlying Issues

ESIs can potentially mask the underlying causes of pain, which may lead to delayed appropriate treatment and possibly worse outcomes in the long term[2]. By numbing nerves and reducing awareness of the body’s signals, ESIs might allow further deterioration to occur unnoticed.

While these studies suggest potential long-term negative effects of ESIs, it’s important to note that more research is needed to fully understand the long-term impacts. The decision to use ESIs should be made on a case-by-case basis, weighing the potential short-term benefits against possible long-term risks.

Citations:
[1] https://emedicine.medscape.com/article/325733-overview
[2] https://nervediscinstitute.com/blog/the-risks-and-side-effects-of-epidural-steroid-injections/
[3] https://www.wolterskluwer.com/en/news/steroid-injection-may-lead-to-worse-outcomes-in-patients-with-spinal-stenosis
[4] https://www.uhcprovider.com/content/dam/provider/docs/public/policies/oxford/epidural-steroid-facet-injections-spinal-pain-ohp.pdf
[5] https://pubmed.ncbi.nlm.nih.gov/21392252/
[6] https://pubmed.ncbi.nlm.nih.gov/35604636/
[7] https://pmc.ncbi.nlm.nih.gov/articles/PMC9296573/
[8] https://pmc.ncbi.nlm.nih.gov/articles/PMC3401142/
[9] https://rapm.bmj.com/content/46/3/203
[10] https://pmc.ncbi.nlm.nih.gov/articles/PMC7508264/
[11] https://academic.oup.com/painmedicine/article/12/5/726/1909636
[12] https://www.vertosmed.com/when-epidural-steroid-injections-esis-dont-provide-lasting-relief/
[13] https://my.clevelandclinic.org/health/treatments/22301-epidural-steroid-injection-esi
[14] https://www.painphysicianjournal.com/current/pdf?article=Nzc4&journal=31
[15] https://academic.oup.com/painmedicine/article/19/3/569/4783111
[16] https://academic.oup.com/rheumatology/article/44/11/1399/2891486
[17] https://www.aafp.org/pubs/afp/issues/2022/0700/fpin-hda-epidural-steroid-injections-low-back-pain.html
[18] https://www.anesth-pain-med.org/upload/pdf/apm-21002.pdf
[19] https://www.vertosmed.com/the-downside-of-repeat-epidural-steroid-injection-treatments-for-lumbar-spinal-stenosis/
[20] https://www.spine-health.com/treatment/injections/epidural-steroid-injection-pain-relief-success-rates

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Answer from Perplexity: pplx.ai/share

Filed under: General Problems | Leave a Comment »

@everyone
If you have one of these charge cards, be careful! We have had one of these charge cards for ~ 9 years. We live off our charge cards. And they have debited our brokerage acct to pay them in full every month.

A few weeks ago, one charge that was supposed to be a automatic debit to this charge card and we got a notice that it was DENIED! I got that resolved and then I got a couple of emails saying that there was a problem with an auto debit with two different companies and gave me a phone number to call to clear things up. I picked up my charge card and called the number on it and was told that there was no problem with our charge card.

Out of precaution, I asked them to just replace our charge cards. It took about one week, but we got new cards in the mail. Within a couple of days of getting those new cards, they had been compromised, two separate charges, one done in Hong Kong for almost $500 for some service that could reload prepaid phones and I don’t remember what the other one was for – but the charge was for a few hundred dollars.

Cancel those cards and request a new set of cards. Took about a week to get those charge cards. Get the new cards and send the numbers to our lawn service. If we pay him for the entire season upfront, he gives us a 10%-12% discount, but the bill is still close to $1,400 for the entire season.

Now, Citi declined the charge. So I made a phone call and in theory, they told me that they had cleared up. The next day I told the lawn service to reprocess the charge, and one again the charge was denied and I get another fraud alert. Once again promised that everything was good to go and customer service asked me if I wanted her to turn off any fraud alerts on my cards, to which I agreed. I told the lawn service to enter the charge again and once again it was denied. At this point I was up the “ladder” the fraud and the customer service person told me to have the lawn service resubmit the charge. I told her that they need to UNDENY the charge. The CS person kept saying she was sorry for any inconvenience, but she could not do that.

I told them I did not wants excuses, I just wanted them to do their job… and I was through with Citi bank, and hung up. I already have new charge cards coming from a different bank and should have them within a week.
I have never had any other business dealing with Citi Bank and after this, don’t plan on changing that in the future.

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@everyone if I described a patient and their health issues and specifics about wanting a practitioner with a DO degree and located in a specific geographic area – could you find possible practice both tradition and/or boutique concierge practices

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Answer from Perplexity: pplx.ai/share

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but you could refine the list down for the pt to make calls or appts

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Answer from Perplexity: pplx.ai/share

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H.R.467 – HALT Fentanyl Act

passed the House 05/25/2023  https://www.congress.gov/bill/118th-congress/house-bill/467

Grassley, Cassidy, Heinrich Propose Permanent Scheduling Fix for Fentanyl-Related Substances

https://www.judiciary.senate.gov/press/rep/releases/grassley-cassidy-heinrich-propose-permanent-scheduling-fix-for-fentanyl-related-substances

Any bill passed in either House DIES at the end of the congressional session. This bill that Congress is trying to pass is basically revoking the FDA’s approval for a drug’s safe use in humans. 

According to Wikipedia, there is some 100-200 different fentanyl analogs https://en.wikipedia.org/wiki/List_of_fentanyl_analogues BUT there are only 3 of those analogs that are approved by the FDA – 2 in humans and 1 in large animals.

All those other different fentanyl analogs are already ILLEGAL substances. From what I have read it is Fentanyl acetate analog that China and the Mex cartels are selling on our streets.

So I asked www.perlexity.ai

Has Congress ever passed a bill to revoke the FDA’s approval that a medication is safe for being safe for humans

Citations:

1. https://www.supremecourt.gov/opinions/23pdf/23-235_n7ip.pdf
2. https://www.texastribune.org/2023/04/07/texas-abortion-drugs-fda-ruling/
3. https://www.akingump.com/en/insights/alerts/congress-year-end-appropriations-package-brings-fda-legislative-changes-leaves-unresolved-policy-issues
4. https://www.facingourrisk.org/privacy-policy-legal/advocacy/federal-right-to-try-legislation-passes-signed-by-president
5. https://www.pbs.org/newshour/politics/5-takeaways-from-the-abortion-pill-case-before-the-u-s-supreme-court
6. https://finstad.house.gov/2024/5/reps-finstad-and-crenshaw-sen-paul-introduce-resolution-to-repeal-harmful-fda-rule-limiting-access-to-laboratory-developed-tests
7. https://www.help.senate.gov/imo/media/doc/FDASLA%20manager’s%20amendment%20SXS.pdf
8. https://www.judiciary.senate.gov/press/releases/congressional-democrats-file-amicus-brief-urging-supreme-court-to-reverse-dangerous-ruling-that-would-restrict-access-to-mifepristone-nationwide-and-upend-fda-approval-process
9. https://www.fda.gov/news-events/congressional-testimony/antitrust-concerns-and-fda-approval-process
10. https://www.congress.gov/bill/118th-congress/senate-bill/603/history
11. https://www.healthindustrywashingtonwatch.com/2024/06/articles/other-health-policy-developments/other-fda-developments/supreme-court-decision-leaves-fda-approval-of-mifepristone-untouched-but-for-how-long/
12. https://pmc.ncbi.nlm.nih.gov/articles/PMC1808190/
13. https://www.congress.gov/bill/118th-congress/senate-bill/606/all-info
14. https://www.kff.org/womens-health-policy/issue-brief/legal-challenges-to-the-fda-approval-of-medication-abortion-pills/
15. https://www.congress.gov/bill/118th-congress/house-bill/7248
16. https://www.fda.gov/about-fda/histories-product-regulation/promoting-safe-effective-drugs-100-years
17. https://www.nytimes.com/2023/04/10/health/abortion-pill-fda.html
18. https://www.congress.gov/bill/117th-congress/senate-bill/4348
19. https://www2.law.umaryland.edu/marshall/crsreports/crsdocuments/RL3279703082005.pdf
20. https://horsford.house.gov/media/in-the-news/supreme-court-unanimously-preserves-access-to-abortion-medication-mifepristone

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Answer from Perplexity: pplx.ai/share

Is it just me, or with it being claimed that 30%+ of members of Congress are attorneys and many judges are making decisions that seems to be in conflict with COMMON SENSE?

Since only 1%-2% of known Fentanyl analogs are approved by the FDA as safe to use in humans or animals. Fentanyl was approved ~ 60+ yrs ago after going thru 10+ yrs of clinical trials and has been available for healthcare practitioners to prescribe for all these decades and a judge or Congress should be able to make it ILLEGAL. Since 98%-99% of all known Fentanyl analogs are already ILLEGAL. If they pass this bill, the bottom line is that they will be overruling all the FDA years of clinical trials and practitioners’ experience using this medication, and make those 3 FDA approved Fentanyl analogs classified as a C-1 and thus become an ILLEGAL MEDICATION – like Heroin

Here is a partial list from www.perplexity.ai – notice that several Fentanyl analogs are listed.

Citations:

1. https://www.drugs.com/article/csa-schedule-1.html
2. https://www.rosalindfranklin.edu/research/centers/research-support-offices/environmental-health-and-safety/controlled-substances/
3. https://en.wikipedia.org/wiki/Controlled_Substances_Act
4. https://www.in.gov/health/overdose-prevention/general-information/drug-schedules-1-5/
5. https://en.wikipedia.org/wiki/List_of_Schedule_I_controlled_substances_(U.S.)
6. https://www.campusdrugprevention.gov/content/drug-scheduling-and-penalties
7. https://www.deadiversion.usdoj.gov/schedules/schedules.html
8. https://www.duffysrehab.com/resources/articles/schedule-of-drugs/
9. https://dhhs.ne.gov/licensure/Open%20Meeting%20Act%20Docs/APRN%205.20.22%20C1a%20DEA%20-%20Midlevel%20Pracitioners%20by%20State.pdf
10. https://uscode.house.gov/view.xhtml?req=%28title%3A21+section%3A812+edition%3Aprelim%29
11. https://www.federalregister.gov/documents/2018/09/28/2018-21121/schedules-of-controlled-substances-placement-in-schedule-v-of-certain-fda-approved-drugs-containing
12. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/schedule-i-drug
13. https://americanaddictioncenters.org/prescription-drugs/classifications
14. https://drexel.edu/studentlife/community-standards/code-of-conduct/drug-free-schools-and-community-act/drug-use
15. https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf
16. https://www.mass.gov/info-details/learn-about-massachusetts-controlled-substances-registration-mcsr-for-practitioners
17. https://www.drugs.com/csa-schedule.html
18. https://www.dea.gov/drug-information/csa
19. https://www.ncbi.nlm.nih.gov/books/NBK557426/
20. https://www.chfs.ky.gov/agencies/os/oig/dai/deppb/Documents/KentuckyScheduledDrugList.pdf

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Answer from Perplexity: pplx.ai/share

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@everyone

This bill has passed the House and there is a similar bill in the Senate but has not been assigned a number yet.  senator young 02172025

The hyperlink above is the letter/email that I sent to Senator Young’s LA who is overseeing this bill. I suggest that you read that letter to help you get up to speed on why making ALL FENTANYL ANALOGS is a bad idea.

PLEASE, JUST DON’T CUT AND PASTE my letter and send it to your two Senators if a politician gets a number of correspondences that are exactly the same thing. they will just believe that the person sending in their correspondence is not their own idea/belief.

This bill means that all Fentanyl products will become a Schedule C-I, basically all Fentanyl products will be ILLEGAL

H.R.467  Halt All Lethal Trafficking of Fentanyl Act or the HALT Fentanyl Act

https://www.congress.gov/bill/118th-congress/house-bill/467

Kelly, Heinrich, Cassidy, Grassley Introduce Bipartisan Halt All Lethal Trafficking of Fentanyl Act

https://www.kelly.senate.gov/newsroom/press-releases/kelly-heinrich-cassidy-grassley-introduce-bipartisan-halt-all-lethal-trafficking-of-fentanyl-act/

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Epidural Steroid Shots for Back Pain Have Limited Efficacy, Review Shows

https://www.medpagetoday.com/neurology/painmanagement/114196

Promising benefits in some situations, but mixed results in others

 

 

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According to www.goodrx.com there is a generic for Advair 100/50 and CVS/Target selling price is $47.42 – LESS THAN THE OPTUM COPAY WAS PREVIOUSLY.  www.singlecare.com shows CVS/Target charging $49.92

Wisconsin man dies after inhaler cost jumps $500, according to family’s lawsuit

https://abcnews.go.com/US/wisconsin-man-dies-after-inhaler-cost-jumps-500/story

A young Wisconsin man died from an asthma attack after the price of his inhaler skyrocketed nearly $500, according to a lawsuit filed by his family.

Cole Schmidtknecht, 22, suffered from asthma, a chronic disease, that he treated with an Advair Diskus inhaler that allegedly cost him no more than $66.

That cost changed last year when OptumRx, a subsidiary of United Health Group, stopped coverage for the inhaler Schidtknecht used for a decade, the lawsuit alleges.

On Jan. 10, 2024, Schmidtknecht went to his local Optum Rx-Walgreens pharmacy in Appleton, Wisconsin, expecting to fill his usual prescription when he was advised by Walgreens that his medication was no longer covered by his insurance and would cost him $539.19 out of pocket, according to the lawsuit.

He was given no notice and, the lawsuit said, Walgreens did not offer him a generic alternative “and further told Cole that there were no cheaper alternatives or generic medications available.”

Unable to afford the inhaler, the lawsuit alleges he left the store without it. “Over the next five days, Cole repeatedly struggled to breathe, relying solely on his old ‘rescue’ (emergency) inhaler to limit his symptoms, because he did not have a preventative inhaler designed for daily use,” his family claims in the lawsuit.

On Jan. 15, 2024, Schmidtknecht was driven to an emergency room by his roommate for a severe asthma attack, but “became unresponsive and pulseless in the car,” before reaching the ER according to the lawsuit.

After receiving cardiopulmonary resuscitation (CPR) in the ER, Schmidtknecht spent days in an intensive care unit and never woke up. He was pronounced dead on Jan. 21 after life-supporting care was stopped, the lawsuit states.

His parents are now suing Walgreens, its parent company Boots Alliance and Optum Rx, the pharmacy benefits manager, for negligence.

“Defendant Optum Rx had a duty to not artificially inflate prescription drug prices for medications such as Advair Diskus for insured patients, including Cole Schmidtknecht, making them so unaffordable that patients could not obtain the medications their physicians prescribed,” the lawsuit said.

In a statement to ABC News, Optum Rx said that Schmidtknecht filled a generic Albuterol prescription, an inhaler used to stop asthma attacks, on Jan. 10, 2024, with a $5 copay, adding that the same drug was previously filled in October 2023 by him.

The prescription service said that it “also has available clinically appropriate options and formulary information” for when medication is not covered by a provider.

In the lawsuit, Schmidtknecht’s family claims “Walgreens Defendants failed to exercise reasonable care in that they knew, or should have known, of the unreasonable risk of harm to asthmatic patients, including Cole Schmidtknecht, that would result from their failing to provide him with Advair Diskus or a medically equivalent alternative medication at an affordable price at the point of service.”

Walgreens declined to comment on the litigation when ABC News reached out for a comment.

Just a few months after Schmidtknecht’s death, the makers of Advair, GSK, announced in March 2024 that starting January 2025 the most people will pay out of pocket for their inhaler is $35 a month.

GSK joined other manufacturers of inhalers in capping the out-of-pocket cost for inhalers, something Sen.Bernie Sanders, a Vermont independent who chairs the HELP Committee commented on at the time.

“The three largest manufacturers of inhalers in the world have all committed to cap the cost of inhalers in the United States at no more than $35 at the pharmacy counter,” he said.

Dr. Jade Cobern, MD, MPH, who is board-certified in pediatrics and general preventive medicine, recommended individuals who suddenly see an increase in medication cost or can no longer afford it speak to their provider about alternatives, check for current discounts to lower out-of-pocket costs by using an app like GoodRx or reach out to the manufacturer for assistance or possible rebates.

“If you are struggling to breathe it is imperative that you seek medical help immediately through your doctor, by going to the emergency room or by calling 911,” Cobern said.

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Below is a video by the community’s beloved Dr Ibsen. Below that is an article that was published yesterday.  Mark has found himself in a tug of war between caring for long term chronic pain pts and the state of Maine which has apparently unofficially declared the state as an “opioid desert”. Apparently, “they” have decided that all chronic pain pts should only be treated with Subutex (buprenorphine), which is technically classified as an opioid.
During the last administration, I heard time and time again the quote “no one is above the law” and I often stated what I believe should be the end of that sentence. ” except those who are in charge of enforcing our laws”

I was always told that when state and federal law are in conflict, the more strict law is to be observed. Mark is trying to function under policies established by the DEA and federal law and apparently, the Maine AG prefers to function under the state law and his interpretation that a practitioner must be licensed in the state of Maine.

The article below, states that some 40 states have codified the 2016 CDC opioid dosing guidelines and “the law of the land”

I see various groups who have gotten some sort of “corrective law” for chronic pain pts being able to get properly treated passed in a few states. But without getting the original law that was codified from the CDC 2016 opioid dosing guidelines repealed, many in charge of enforcing the laws are able to pick and chose which laws they wish to enforce.  This does not provide the practitioners in the state nor the pts if the new law will provide any safe harbor or protection in getting their medically necessary meds.

• Estimates: Some experts suggest there may be approximately 300,000 federal statutes when including criminal offenses, agency regulations, and other legal instruments2. However, this number is an estimate and not definitive.

In summary, while the U.S. legal system has extensive documentation like the Statutes at Large and the U.S. Code, no comprehensive tally exists due to the dynamic nature of lawmaking and enforcement.

I once read a quote from someone. “we have 12-15 million laws, rules, regulations…just to get us to obey the TEN COMMANDMENTS”

The CDC’s Big Mistake

https://www.americanthinker.com/articles/2025/02/the_cdc_s_big_mistake.html

President Trump’s first week in office included an order suspending all CDC, HHS, and NIH communications: regulations, announcements, reports, advisories, updates, and online posts.  This aligns with pruning federal bureaucracy.  But silencing these three, of hundreds of agencies, is interesting.

COVID was, for many Americans, their first personal experience of vast, unregulated power imposed by federal agencies.  Without enforcing laws or interpreting regulations, just publishing claims and data can have unrestrained power.

For many Americans, it was shocking and novel seeing suggestions rapidly morph into mandates, while mainstream and social media stripped contradictory evidence and contrary opinions from public discourse.  Some citizens were inspired to push others to wear masks.

But COVID wasn’t the first time government actions that were neither laws nor regulations imposed dire consequences on ordinary, law-abiding Americans.

One agency muzzled by Trump, the CDC, exemplifies far-reaching federal influence.  One example of the profound impact of CDC publications is the 2016 CDC guidelines for pain treatment with opioids.  These guidelines — not regulations, not laws — initiated drastic, ongoing reductions in pain care nationwide.

The guidelines discussed pain patients who had never been prescribed opioids.  The CDC recommended for these patients doses below 90MME per day.  The guidelines didn’t discuss established patients with severe and chronic pain, or the wide genetic variability of sensitivity to pain and sensitivity to opioids.  Although pain is often described as a subjective experience, it’s  observable in animals and people unable to verbalize, including infants, coma patients, and  dementia patients.  Four of the top ten reasons for U.S. E.R. visits are pain (abdomen, chest, head, and general).  Another, back problems, entails pain.  Only for Spock, a fictional alien, is pain merely “a thing of the mind.”

Caution introducing new medication sounds reasonable.  However, variability in pain and opioid sensitivity makes a one-size dosing, even for one subset of patients, or medical condition, unworkable.  Chronic and severe pain often requires much more than 90 MME per day.  Individual morphine tablets of 200mg are legally manufactured and prescribed.

Between 2011 and 2021, U.S. opioid prescriptions were down 40%.  According to JAMA, from 2016 to 2018, prescriptions were down sharply.  This trend began years before the guidelines.

After 2016, many insurers and medical groups, and state governments, drastically reduced prescribing these drugs, even for long established, successfully treated patients.  The 90 MME limit is currently enshrined in laws in 40 states, often applying to all pain patients.  Inpatient palliative care, especially for economically disadvantaged patients, has been significantly reduced.

In 2014, approximately 39.4 million Americans suffered chronic and severe pain.  As of 2024, that number was over 60 million.  In 2016, 1 in 10 U.S. veterans had chronic pain, and after the guidelines were published, veterans complained of insufficient pain treatment and rising veteran suicides.

Facing widespread criticism, CDC expressed surprise that the guidelines had been applied widely and swiftly.  In a 2019 paper, the guidelines’ authors claimed that recommendations had been implemented incorrectly and pain patients were being deprived of necessary medications.  Revised guidelines published in 2022 softened some recommendations, with no effect on post-2016 legislation.

The 2016 guidelines didn’t arise in a vacuum.  Years of prior CDC publications featured flawed data.  There was a detectable inference that legally manufactured opioids prescribed by professionals present a uniquely serious threat not only to patients, but to society.

To illustrate how prescription opioid deaths were supposedly underreported, a 2017 CDC report discussed Minnesota patients with pneumonia and opioid prescriptions who died between 2006 and 2015.  The CDC argued that these should be counted as opioid deaths, not pneumonia deaths, as they had been.

A 2021 report in the medical journal Cureus examined a decade of CDC publications about opioid-linked deaths.  From 2006 to 2016, CDC’s opioid prescription death totals were inflated by counting deaths linked to illicit fentanyl and methadone dispensed for substance abuse treatment.  Methadone prescriptions for pain started declining prior to 2016.  “What is clear from the authors’ inquiry is that, even today, the CDC has no way of determining the actual number of prescription opioid overdose deaths each year.  For more than a decade, the CDC’s erroneous reports went unchallenged while being used by Congress and the Executive Branch as the basis for public policy.”

A 2021 Pain Therapy report shows that death attributed to opioids were over-reported by 20–30% — virtually the same percentage by which the CDC claimed opioid deaths were increasing.  Almost 90% of deaths attributed to opioids included 1–4 other drugs on the death certificate, most frequently benzodiazepines.  A 2021 CDC publication bluntly states that agency efforts to quantify overdose deaths are “falling short.”  As of 2021, the CDC hadn’t complied with Congress’s mandate to improve its methods for tabulating OD deaths.  Whereas one CDC publication reported that opioid deaths were up in 2020, another, in 2023, stated that they were up for the first time since 2018.

Considering the influence wrought by one publication on one subset of patients, data on that subset might be pertinent.  A 2018 study in the BJM studied over two million opioid-naïve patients receiving surgery between 2008 and 2016.  Their subsequent opioid misuse rate was 0.6%.

In 2016, JAMA published data for 641,941 subjects, with no opioid prescriptions for at least a year, receiving major surgery between 2001 and 2013.  The reference sample of 18 million received no surgery.  Depending on the surgery, rates of subsequent misuse ranged from 0.119% following C-sections, to 1.141% for total knee replacement.  For the no-surgery control group, the rate was 0.136%.

Despite revised guidelines, and documented flaws in their opioid data, the CDC continues to publish flawed data.  The influence of the 2016 guidelines continues to spread.  We now have a return of opioid-free surgery, as well as the opioid-free emergency room.

Many medical professionals fear prescribing appropriate opioids from the misguided belief that opioid prescriptions are uniquely lethally dangerous, or fear facing legal battles like the plaintiffs in the Supreme Court Ruan case.

The influence the CDC exerted via publications alone cannot be undone with publications.  At this point, CDC officials could appear in sackcloth and ashes, on social media blast, vigorously repenting of the 2016 guidelines, without affecting the sequela of their work in 2016.

For reasonable pain care, we’d need

1. legislatures in 40 states to repeal post 2016 laws,
2. professional medical education to cease depicting prescribed opioids as uniquely dangerous to patients and society, and
3. the White House to stop financial rewards for Hollywood productions pushing narratives crafted by government drug warriors.

Even if all effects of the 2016 guidelines were entirely reversed, it will do nothing for patients who died by suicide following the sudden withdrawal or forced tapering of their prescriptions.  That number has not been the subject of any federal research.

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