Medicare Appeal for Buprenorphine

[teakabeagle]

Just finished the Medicare hearing for the Buprenorphine trial. The pharmacy company( Cigna) did not appear. My case was reviewed , medical necessity accepted but no decision on permitting off label use at this time. His parting statement was I understand it works well for you, but we have to consider the formulary guidelines., so it sounds like a denial. At worst, it will have a case number and be part of the records. It will not get into the formulary unless there are cases. I reviewed all cases for Buprenorphine for the past 10 years and none were for RLS. Will post the final decision once I have received it.

[Joolsg]

Can you email Andy Berkowski and ask for extra evidence? He has lots of patients doing brilliantly on Buprenorphine.

[e-mail]

[teakabeagle in reply to Joolsg]

The trial anopeal is already over annd now I wait for his decisions. I included several articles and blogs from Berkowski, Winkleman, Buchfuhrer as well as the algorithms from Mayo, Cleveland and AASM. I had a long discussion with the judge who asked a lot of questions for clarification.

[707twitcher]

Were you trying to get the buprenorphine patch, or the sublinguals? I've been getting sublingual Rx filled without question for 16 months (Suboxone film - 2mg bup, .5mg naloxone). But when I switched to the patch briefly, that triggered review and denial (I didn't go through appeal process). I suspect that's because the patch is significantly more expensive. Some people do better on the patch, but the fact that its effectiveness over a 7-day period looks like a bell curve - high at peak effectiveness days 2-4, but more than 50% lower before and after - makes it difficult to find correct dose and know when to replace (almost no one gets 7 days use out of a 7-day patch). Even without insurance, I think you can get suboxone via GoodRx for $40 or so for 30 films. A lot of us use .5mg or less, so 30 films would last 4 months (cut into 1/4s).

[teakabeagle in reply to 707twitcher]

I use the tablets, which works well for me. That was denied from the start. It was denied on the first two level of appeals, both for lack of medical necessity and off label use. Both issues addressed on the appeals. Third level is an informal hearing with a judge who is part of HHR.

I reviewed all the third level appeals for Buprenorphine, about 1500 of them. Most for off label use for chronic pain for various reasons including arthritis, migraine neuralgia. There are none for RLS. This appeal at least gets RLS included. I think Bup will be used more for chronic, severe, resistant RLS, so it needs to be in there.

I can use a discount coupon, but in my area, they don’t allow co ti you’d use of them for narcotics. A lot of the pharmacies in this area have list their license to dispense narcotics for various “ bad behaviors”. You shop around for pharmacies to use coupons or the best prices, you get “red flagged” , which is a major problem for you. Out of pocket cost in my area ranges from $140- $170. Not huge, but it adds up.

The appeal was easy to write and I included all the material supporting its use in RLS, the algorithms, the RLS opioid study. I had a long talk with the judge around the off label use. He agreed to the medical necessity, but said he had to consider the formularies in determining his decision.

There are still two mor level of appeals which I may or may not pursue. I can’t afford an attorney, so they may preclude that.

[SueJohnson in reply to 707twitcher]

Unfortunately different regions have different rules for Medicare.

[teakabeagle in reply to SueJohnson]

So true. In this area, medicare c an be a pain, especially if you have an advantage plan( Idon’t have advantage). Thank God other than my now well controlled depression, I have no other health issues.