Medicare and medication coverage

[teakabeagle]

I’m curious- Is anyone out there having trouble getting coverage from Medicare for “regular”Gabapentin and Pregabalin? I’m getting STRONG resistance for the Buprenorphine due to its off label use and “lack of medical necessity”. Regular Gabapentin and Pregabalin still do not have FDA approval(Gabapentin Enacarbil does have FDA approval), and I’m pretty sure it is being covered. I’m feeling it’s the Buprenorphine, , especially being in Northern California that is going bonkers over opioids right now. I also think lack of education, and the impact of RLS on quality of life is playing a part which I don’t think anyone finds surprising.

Anyways, doing a third level appeal and shoring up what my doctor failed to get across on the first two. This is an informal hearing, so I have a chance to educate on treatment, including off label use, as well as RLS impact on quality of life.

[SueJohnson]

I just have pregabalin and gabapentin prescriptions and it is covered under my Part D insurance and since your can choose that I always make sure to choose one that covers it. I'm in Virginia.

Don't know about buprenorphine.

[teakabeagle in reply to SueJohnson]

My part D does cover Buprenorphine, but they are denying it as it is off label( they don’t tell you it is covered for OUD, and it still need prior approval and there are quantity limits. ). They do cover Gabapentin and pregabalin, but both of those are also off label for RLS, so who knows if they would cover the off label use (The only form of Gabapentin approved for RLS is Gabapentin Enacarbil, and that also requires prior approval.) That was true for all the Part D’s in my area (there are only 4 available in my area)The only other approved drugs for RLS are the DA’s and the insurance company is fine with those without prior approval.

[SueJohnson in reply to teakabeagle]

Of course they are fine with DAs! Ahrrr!

[teakabeagle]

Right?! I hate how these Dr. don’t bother to educate themselves on the latest trends. They just go to the internet and look at the first thing that comes up which are those freaking DA’s

[Ticki]

This is my fear too, because I turn 65 in March and I worry that’s what might happen to me when I lose my old Insurance Policy and have to deal with them.The struggle never seems to end.❤️‍🩹

[teakabeagle in reply to Ticki]

So true. Don’t be fooled by the formulary. It may say it is covered, but , depending on the state and the insurance, it may only be covered for FDA uses. My info booklet Part D sent me does not say that. When I got the first denial I called and got the scoop. They also do not outline that there are 5 levels of appeals. I am on the 3 rd level which will involve an hearing, usually by televised. In general, the squeaky wheel gets the grease if you have done your homework. We shall see.

[Tanker1]

I've had no trouble with getting medicare and part D to cover pregabalin and gabapentin. I could not get coverage for Grailise which is a slow release form of gabapentin. Your trouble might be with your state or your part D insurance. I live in Washington state. This is the response from my insurance company at the time (2021) that I provided to my sleep doc : "I got a call from my prescription drug plan and they denied the request for Gralise. The reason is that it is not approved by the FDA; or supported by citation in one of the specified drug compendia, including the American Hospital Formulary Service-Drug Information (AHFS-DI) and DRUGDEX." I provide this in case you want to do some research into your drug plan or state regulations.

[teakabeagle in reply to Tanker1]

Yes, Graluae is only FDA approved for post herpetic neuralgia. The only Gabapentinoids FDA approved Ed for RLS is Gabapentin Enacarbil( Horizant).

It took years for Gabapentin and Pregabalin to be a. Wired as off label for RLS and the same will eventually be true is Buprenorphine. If these denials aren’t appealed with vigor it will not happen. I wrote appeals for Worker’s Compensation IMR denials( supposedly ironclad) and got reversals. I have the time and the stubbornness to give it a go. I still have two more levels to resort to if needed.

[707twitcher]

I’ve had no trouble getting Medicare (and supplement) coverage for gabapentin, pregabalin, dipyridamole, and suboxone (buprenorphine sublingual strips). However when I switched briefly to the buprenorphine patches, I got pushback. My guess is because the cost is much higher than for sublinguals. Switched back to Suboxone after a month, and no problem with coverage ever since. 🤔🤔🤔

I’m also in northern CA.

Do you have a Medicare Advantage plan? If so, the private insurer who runs it might be the one blocking this?