Pharmacist Steve---Question re: Exalgo Dosage

[Eva 14]

Steve, I appreciate any help you can give me.

My pain doctor wrote me a script for Exalgo. My doc wrote my script for MORE than 64 mg. to try to convert from the Avinza dosage I've been taking.

My insurance is refusing to pay for more than 64 mg. per day. It's an expensive med, so I sort of understand. However, I haven't gotten a clear answer from my insurance as to WHY they won't pay for more than 64. mg. per day.

One person I talked to on the phone at insurance said that the FDA has a MAXIMUM dosage of 64 mg. on Exalgo? Is this true?

My other question: Can a pharmacist fill a C-II script for LESS than the quantity it's written for? (My script is for #180 Exalgo. Can the pharm fill the script for #120?).

I just want to make sure that I won't need to get a NEW script from the doctor, since it's a LONG drive to the doctor.

Thanks for any help!

Eva

[Pharmacist.steve]

The "recommended" dose - per the manufacturer's insert is 8mg -64 mg every 24 hrs. Probably because the manufacturer didn't test any higher doses on patients during clinical trials. The manufacturer is probably protecting itself with that recommendations.. and the insurance company are hanging their hat on that recommendation to limit their expenses. Nothing in the insurance industry is in concrete.. ask the insurance company what the appeal process is.. they don't have to tell you about having an appeal process - if you don't ask..but if you ask.. they have to provide you how it works - usually in writing. Usually around 50% of patients who appeal such decisions ... win and get things paid for. The appeal process could have several levels.. keep pushing the issue.. increases your probability of getting it paid for.. The easier & cheapest thing for the insurance company to do is deny a claim... it put the task on the patient to go thru the process of appealing.. they count on a majority to just accept their NO.. and go away...
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I have had to "fight" the insurance company for one of my wife's off-label meds.. They count on the patient not being mentally/physically up to dealing with their bureaucracy .. in my case .. when they found out that I was a Pharmacist - and not the patient - they CAVED and paid for it... I am right now in another fight.. they took one of her meds off the formulary when the new year started... she is not out.. and I am waiting for a form for the patient to fill out for a formulary over-ride.. I never heard of a patient request form... and only found out because I laid all my cards on the table... do you really want to go up against a Pharmacist in the appeal process.. I haven't won yet.. but.. I would put money that I will come out on top when everything is said and done.
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From a technical stand point .. dosing above 64 mg/day is "off label" and many insurance companies are putting off-label prescribing as "experimental" and most policies don't cover experimental drugs.. In reality.. over 50% of all prescriptions are for patient for off-label reasons.

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Pharmacy practice acts different in every state.. however.. typically, if a Pharmacist partially filled a C-II prescription.. one of two things have to happen.. they have to be able to furnish the balance within 72 hrs.. or the Rx is void for the balance and the Pharmacist should notify the prescriber that the patient did not get all that was written for... because stock was not available.
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There is no reason that the doc cannot mail you a new Rx or mail it to your pharmacy of choice for the balance.. unless the doc is just hard-headed.
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IMO.. your doc is fully aware that there is no real upper limit to opiate dosing.. it all depends on the patient previous built up tolerance to opiates.
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Go get them EVA... kick them in the A$$

[Eva 14]

Thanks, Steve! That's excellent information about the appeal process; I never really knew that there was an appeal process. Exalgo ER must be the most expensive of all of the ER pain meds. So many of the drugs for chronic pain are so expensive, even with insurance.

Thanks,
Eva

[alex44]

Eva - I USED to get 180 pills. The insurancw company refused to pay saying i can achive the same dose with 90 pills and that is all they will pay for. - this eliminates any flexability for me to take LESS - IMHO, this sucks. Oh well, something is better then nothing. Good luck and keep fighting and asking questions. Good luck and hope this finds you well.
Blessings
Alex44
Skypilot

[Pharmacist.steve]

Eva.. in your conversations with the insurance company... if they give you any "lip".. I would just "mention" in the conversation that you wonder how the insurance commissioner will feel about an insurance company denying a patient adequate pain management.. when it could be achieved..
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You might also might want to "mention" that you may be forced to seek legal advice because some people believe denying a patient adequate pain management is a form of patient/senior abuse..

There have been a few lawsuits against docs that have not provided adequate pain management in end of life patients and they were sued with senior abuse and the docs lost.. to the tune of ONE MILLION dollar each..
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If your doc needs to write a letter as part of the appeal process.. suggest that he/she put a phrase in there that unless you get the medication you need that he/she is going to recommend that you seek legal advice because of patient/senior abuse the insurance company is causing..

that should get their attention...

[Eva 14]

Thanks for your advice, Steve. When I called my insurance company today, I was pretty amazed to find out that they finally did APPROVE my Exalgo dosage. I guess their talk of an "FDA limit" of 64 mg. was just an excuse to try to not pay for it.

I have a high deductible and a pretty high monthly premium, so my insurance company gets a lot of money from me.

Still, I was pretty shocked at the final price----$4,000 per month! After I meet my deductible, I only need to pay $150 per month, as I would for ANY brand-name drug. My dosage is only slightly higher than the "recommended" 64 mg., so Exalgo has got to be one of the most expensive meds out there!

I've read of certain cancer drugs or HIV meds costing thousands of dollars per month, or the occasional case of expensive meds for very rare diseases. Besides that, it would seem that the only other class of drugs that is so costly is certain long-acting pain medications. I know that the pharmacy staff was pretty shocked at the high price, too, and they fill all sorts of different meds every day.

I guess the drug companies justify their exorbitant prices because these are 24-hour time released long-acting meds? Sometimes I don't know how they can justify such a high price on a DAILY medication. I know that methadone is long-acting and very cheap, so just because a med is "long-acting" doesn't seem like a good enough reason to hike the price up so high.

Avinza is very expensive, I know that Oxycontin is expensive, presumably Opana and the fentanyl patch are expensive, etc. I know that Actiq/Fentora is super expensive. I feel like we who are in chronic pain are being unfairly burdened by these exorbitant medication prices. A drug company would never charge so much for a high blood pressure med or a high cholesterol med. I guess the drug companies know that people in pain are DESPERATE for relief and they seem to think that we will pay anything for that relief. Assuming that we even have the means to pay these prices, which most people don't.

I'm sure that someday I'll need to switch to something generic just to save money, assuming that there even IS anything generic that is cheap and effective. Methadone is the only med I can think of that fits those criteria, but it seems like most pain docs don't want to prescribe it. I guess pain docs are somehow influenced by methadone's stigma when deciding on which opiate to prescibe. That's a shame, because most people who are in pain cannot work and therefore cannot afford expensive medications.

Do you think that chronic pain patients are getting a raw deal from the drug companies by being stuck with these high prices? It's expecially unsettling because these meds need to be taken every single day, not just occasionally.

Thanks again!

Eva

[tortoisegirl]

Sadly enough your Exalgo cost doesn't shock me...I'm numb to those costs now. No wonder they are now pushing the high deductible plans now, as it makes the patient accountable for costs. Your share of $150 is quite steep....wow. I pay a lot extra for insurance for good prescription coverage so the max I pay is $45, as I have at times taken meds that cost thousands per month. I'm surprised they covered it. Some insurances now make you fail cheaper meds before covering expensive ones.

Kadian is now generic but I don't think its much cheaper (although may make a big difference in copay on a tier system). Besides that, for long acting meds, I think its only methadone, fentanyl, and very recently, Opana ER, of which only methadone is considered inexpensive. The cash price for my methadone is under $50, and its a higher dose. When I was on fentanyl patches it was definitely hundreds a month for the generic.

Yes its a shame they can be so expensive, but they do have to spend millions upon millions of dollars now to get a drug FDA approved, especially one that can be controversial. You'd think they would recoup the costs quicker with pain meds than something that has less of a market share though. Best wishes.

[Pharmacist.steve]

Using Morphine SR every 8 hrs.. typically provides good pain management.. if dosed appropriately... fentanyl patches I believed have dropped in price... Methadone is cheap.. but.. the tablet itself is not a long acting tablet.. the half of the drug is very long and highly variable from patient to patient.. it can also cause some cardiac problems... IMO.. it is best to be used in patients that can't afford anything else..