Off Label Use & Medicare?

[fastspinW]

Does anybody know what sort of problems I am going to run into since becoming covered by Medicare. I have a Medicare Advantage policy with Part D drug coverage and was reading the 100 page “Owners Manual” today. To my horror I noticed a section that said that the plan would not cover “Off Label” use of drugs being taken. I’m pretty sure that almost all the AP drugs being used here represent “off label” usage and can’t help but wonder what will happen if my insurance company discovers that I am taking them for RA. Has anybody had any experience with this?

Thanks,
Winston

[Jan Lucinda1]

I got approved for minocycline but it took a Prior Authorization.

Good luck.

[Maz]

@fastspinW wrote:

To my horror I noticed a section that said that the plan would not cover “Off Label” use of drugs being taken. I’m pretty sure that almost all the AP drugs being used here represent “off label” usage and can’t help but wonder what will happen if my insurance company discovers that I am taking them for RA. Has anybody had any experience with this?

Hi Winston,

If you need to get special authorization for minocycline on Medicare, as Jan Lucinda managed to do, there is always the fact that the gold standard drugs like methotrexate, plaquenil, gold, etc, were all drugs designed for entirely different purposes and are still today used off-label for RA. Fortunately, minocycline is listed as an approved ACR DMARD with off-label use for RA, so this is another plus…unless your Medicare plan would rather pay the cost of a biologic? 😉

http://www.blackwellpublishing.com/acrmeeting/abstract.asp?MeetingID=761&id=80039

http://www.rheumatology.org/practice/clinical/patients/medications/minocycline.asp

Hopefully, this won’t be a problem for you, though if you are wanting brand, you may need to argue this a bit more strongly. Patients who suffer from reflux have managed to get brand rx’d as the pelleted version of Minocin seems to be absorbed in time-released fashion and is less likely to cause reflux.

Winston, there is a lady in your neck of the woods who is seeing Dr. E. and she has been trying to get logged back into the forum to answer your question about this doc. She may PM you when she gets back in again (unless she has already).

Hope all else is well your way!

[fastspinW]

Maz,

I’m not actually trying to get approval for Minocin. I did manage to get it several years ago when I was using Minocin with private insurance but I had to switch to doxy due to Minocin induced leg cramps. What I was after in this post is whether or not I will have tough sledding with Medicare in terms of overall AP therapy? Should I, for instance, need a clindamycin IV?

I will say that I am greatly concerned with this “off label” BS! Over the course of forty long and difficult years of battling chronic illness and insurance companies I’ve seldom before run into this being used as a criteria as to whether or not an insurance company will pay for a particular drug. I did have to deal with it 5 years back when I used Minocin but given the price of that drug!!!! and the never ending increases in cost since then I could understand insurance companies asking for proof that brand name is better.

Reading my Medicare Advantage policy the other day, however, the thought occurred to me that insurance companies are getting more and more aggressive these days when it comes to denial of benefits. Doesn’t take much imagination to see that the entire AP therapy could be seriously effected should they get picky about doxy etc. Worrisome doesn’t cover how I feel about this…

Speaking of scum bag insurance company practices I recently ran afoul of another new “creative” way for them to force me to shoulder more of my drug expenses. To whit my Medicare Advantage plan has a 3 tiered price structure (generic, preferred name brand, no preferred name brand) with both a 30 and 90 day supply option. When I filled a script for Levemir insulin 2 days ago I was horrified to discover that the $105 charge I paid for a 90 day supply (1 bottle) was only $18.50 less than the full cost of the insulin! The 90 day supply of brand name Synthroid I take for underactive thyroid costs less at full price in Canada then the copay I would pay for a 30 day supply in the US!!!!!!

And speaking of Medicare and drug costs Levemir went from $84 a bottle to $123.50 a bottle in one price jump just weeks after Obama announced the supposed 50% discount seniors would receive for drugs purchased within the infamous Donut Hole. Other of my drugs experienced similar price increases and continue too today. Soooo the 50% discount appears to be just another shuck and dive trick between Washington and Big Pharma…

Occupy Wall Street? Heck with that, just cut to the chase and occupy Washington D.C!

Thanks by the way for the heads up on the lady seeing Dr. E. I did hear from the first lady you mentioned and she had to switch docs because of insurance issues. Is this lady you mention someone else?

All best,
Winston

[Maz]

@fastspinW wrote:

Thanks by the way for the heads up on the lady seeing Dr. E. I did hear from the first lady you mentioned and she had to switch docs because of insurance issues. Is this lady you mention someone else?

Hi Winston,

Believe me, I really understand your angst over insurance issues – I just got refused any further coverage for my abx as coded for Lyme. They’ve covered me for 5 years, but it appears azithromycin caused a red flag to go up when I had to switch to it for a month from biaxin as my pharmacy no longer stocked it. Yea, it really sucks…I now pay all my out-of-network physician consults and all my meds on my own…only standard lab fees are covered now. And, lab costs are a real crock! I get little notes from Cigna saying that my labs cost this extortionate amount, but because of Cigna’s special relationship with Quest, I get and 87% saving and only have to pay “so much???” 🙄 I agree, something really has to give. I guess Canada is fortunate in one way – they have drug ceilings to control pharmaceutical profiteering. In another way, not so fortunate – nationalized health care physicians very rarely stray from prescribed standards of care and, the rare ones that do, work out of network. This is why Canadians have such a hard time finding any doc willing to help with AP and Lymies have to travel to the US for treatment.

With regard to IV clindamycin, the more experienced AP docs will code these for mycoplasma infection, rather than for RA, so there usually isn’t a problem. If you decide to try IVs, then I can send you Dr. S’s contact info and he should be able to let you know how this is done…or will consult with Dr. E. for you if needed…sometimes it’s all in the “coding.”

Susan48 was the lady I mentioned who you could PM about Dr. E., but there is another lady up your way who saw your thread about Dr. E.,but was having trouble getting logged back into the site. Lynnie has helped her with this and hopefully she will be in touch with you soon. I will PM you her name.

[PhilC]

Hi Maz,
@Maz wrote:

Believe me, I really understand your angst over insurance issues – I just got refused any further coverage for my abx as coded for Lyme. They’ve covered me for 5 years, but it appears azithromycin caused a red flag to go up when I had to switch to it for a month from biaxin as my pharmacy no longer stocked it.

Ouch, I am sorry to learn of that. But I am very glad that fastspinW brought this up and I saw your reply to him. I was wondering if being prescribed a month’s worth of azithromycin could raise a red flag, and now I know the answer.

Was your prescription for azithromycin filled with the brand name or a generic? I wonder if that would make a difference.

Phil

"Unthinking respect for authority is the greatest enemy of truth."
- Albert Einstein

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