Patty has MS, Crohn’s, severe spinal damage from an infection and is going to have major fusion surgery Feb 14th, 2018. Her Part D Envisions RX company is requiring an ‘Opioid Safety’ form. Patty has been caught between the company and her doctor’s office, as the company has said they haven’t received the paperwork. However, the doctor’s office provided time/date stamped copies to her. It has now been denied twice, although approved last month, and Patty has been stable on these medications (Opana ER and Hydromorphone, but they only approved the Hydromophone) for 11 months, and has been on daily opioids for 17 years.
Envisions RX is now sending it to a third party for approval, with the Clinical Director refusing to review the file. The doctor’s office is insisting that everything has been done right. Additionally, the doctor appears to think if he just changes Patty’s medication, it will get approved. Patty is stable on her medication, and would the ‘Opioid Safety’ form would still be necessary.
According to your article ‘Using the PA Process to Deny Necessary Medication‘, Patty should talk to Medicare and file an ’emergency determination’ with Envisions RX and the third party company to receive an answer in 72 hours. Patty had both these medications approved on Dec. 12th, 2017 which were pre authorized until Dec. 31st, 2018. This “Opioid Safety’ form appears to just be a formality, as the medications have already been approved? Furthermore, the Hydromorphone didn’t appear to need the safety form, just the Opana ER?? Patty believes the safety form is required for medications over 200 MME?
This situation has been extremely stressful for Patty. Her sister was kind enough to pay for the outrageous $1400 for the Opana ER, but obviously can’t do that on a regular basis. Patty is preparing for a very serious surgery, and the stress has increased her blood pressure to up to 223/138, which is extremely dangerous and they wanted to call the paramedics. Since then, her blood pressure has continued to be dangerously high. Can you please advise Patty with the details she should include in her 72 hour emergency appeal request? Her number is xxx-xxx-xxxx and she is copied on this email, as well.
Thank you for all you do and publish for our pain community. Without your knowledge and dedication, we would continue to drift even more.
Filed under: General Problems
A family member has a new pain problem in addition to the old stuff ,doctor upped the medication till this can be resolved . Authorizations were sent 3 days ago. Insurance approved the hydrophone but waiting for mscontin . It’s a very high dose according today’s hysteria even with out the increase ,tomorrow will be day one with no ms contin after 10 years . Waiting for authorization. It will be a shock to my family member’s system .The pain will be out of control for sure. Cash pay over 500. on SSDI is impossible. Should i take this family member to the hospital ? Worried
Unless it was specified when the PA was requested that it was an EMERGENCY – they will take up to 30 days… if claimed it was an emergency should be 24-72 hrs. Suggest someone call the insurance tomorrow and tell the insurance company that unless they meds are granted ASAP… the pt will end up in the hospital… most likely the insurance company will do the $$$ calculation that it will be less expensive to approve the oral meds than the thousands/day that they will pay out for being hospitalized
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