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        Cluster Headache Help and Support >> Medications, Treatments, Therapies >> Fentora  [Fentanyl Citrate]
        
(Message started by: DannyV on May 9^th, 2007, 2:55am)

Title: Fentora [Fentanyl Citrate]
Post by DannyV on May 9^th, 2007, 2:55am

I was in a study for this drug which is a FAST acting opioid designed for breakthru pain in opioid tollerant patients. It goes between your cheek and gum and kicks in in about 10 minutes. 1-2-4-6-and 800 mcgm tabs. If you are on long acting opioids and are in need of something that works FAST for attacks this may help. The drug is now FDA approved and on the market.
Now, ironically, my doc wrote me a script for it and my insurance co. won't cover it. He wrote them a letter. Still no. Doc is a busy man and says that that is all he can do.Is there anything I can do to get the ins. co to cover this?

Title: Re: Fentora [Fentanyl Citrate]
Post by BikerBob on May 9^th, 2007, 3:24am

Forget about the insurance company for now.

Get a new doctor if your doctor is prescribing an opioid agonist for CH and says that's "all he can do".

BB

Title: Re: Fentora [Fentanyl Citrate]
Post by DannyV on May 9^th, 2007, 10:10am

He meant that was all he could do as far as dealing with the ins. co. as far as THAT drug goes. I want to take it.
The only other thing that I know of that helps as quickly is STADOL NS, but I can't take that. The key word here being"helps" not cures.

Title: Re: Fentora [Fentanyl Citrate]
Post by Katherinecm on May 9^th, 2007, 2:11pm

Let's not get into the opioid debate again. If Danny has taken enough to develop a tolerance it's pretty safe to assume that 1)he's in the minority of us that it does help and 2)he's dealt with CH long enough to rule out other options.

Danny,

Before you go to all this trouble, have you tried a sample of this drug to see if it's worth it or not?

There are two options to deal with this if this is insurance through your employer. The first is to contact your human resources department and ask for help. If you're in a large enough company they will have a benefits coordinator whose sole job it is to deal with things like this. They will be able to explain how the policy is written if for some reason this med is specifically excluded, and possibly negotiate that next year the med will be covered. If it's not specifically excluded they will be able to contact your insurance administrator for you and put some pressure on. It's amazing how fast that can work, especially at this time of year when they may be evaluating changing policies, contracts, and administrators for next year.

If that doesn't help or if you have an individual policy, block out several hours (Thursday afternoon is usually best) to call your insurance administrator and complain. Don't bother to speak with the first person who answers the phone- they will take some time to read through the notes on your file and more or less parrot back the same decision that has already been made. You want to ask for their supervisor, and then probably their supervisor after that in order to get this taken care of quickly (quickly being a relative term). Be aware that you may be on hold for quite a while waiting for a manager if the administrator has a particularly small office.

When you get the manager on the phone explain to them that you have cluster headaches, that it is NOT related to migraines and is so rare there are few established treatment protocols and that due to your not responding to typical medications that you need this particular drug. Use the term "medically necessary" a lot. Establish that they have indeed received the letter from your doctor, ask what else you need to do to prove that this treatment is NOT experimental and is medically necessary.

You may need to have your doctor send them more medical records to establish that you have indeed ruled out other less expensive options first. If you haven't tried everything else (at the very least one drug from each class of known treatments both abortive and preventative) get ready to be denied. Your policy is probably written specifically to cover only the least expensive treatment that works and is medically necessary. Sometimes if you have a history of expensive treatments (more expensive than this drug, such as going to the ER a lot) by policy this will be faster to establish.

Be polite but firm. Do not let them talk you out of it or let them brush you off, and don't get offended if they try to do so. Your policy is written to try and keep costs down for everyone and to not pay for unnecessary treatment. This is a good thing, if it wasn't done this way the insurance would cost MUCH more and there would be MUCH more fraud. The policy is written and by law they must follow it.

In the event that none of this helps, let your insurance company know that you think they are fraudulently violating your policy by not covering a medically necessary treatment and that you will be contacting your state's insurance commissioner and/or an attorney. If there is in fact some sort of fraud going on this will oftentimes get it fixed in less than 24 hours because they DO NOT want to be fined or lose their ability to sell insurance in your state.

If none of this works, google your state's insurance commissioner and call in to file a complaint. They will open an investigation for you and either fix it or prevent this from happening in the future.

Hope that helps,
Katy

Title: Re: Fentora [Fentanyl Citrate]
Post by Katherinecm on May 9^th, 2007, 2:18pm

Oh, one more thing: you may want to seriously consider another doctor. The idea that (s)he is too busy to get you the treatment you deserve raises some serious questions in my mind. The doctor is going to have staff to deal with most of this. If they can't be bothered I would seriously question whether they can be bothered to keep on the research for CH or not, which involves a much larger investment of time.

Title: Re: Fentora [Fentanyl Citrate]
Post by DannyV on May 9^th, 2007, 10:12pm

What a vast frontier of knowledge you posess on this scenario. I am going to start your reccomendations tommorow. I can't thank you enough. You're a doll.

Title: Re: Fentora [Fentanyl Citrate]
Post by DannyV on May 10^th, 2007, 4:45am

To answer some of your questions, As I mentioned, I was in a placebo free study for this drug for 6 months and YES it helped me.
My previos doctor recomended the same thing you did about going to our company[Which is huge] and asking the benifits coordinator to help with issues like this. They basically told me that they dont get involved in problems between Docs and the Ins. Co.
I have also gone as far as I could on the phone with Ins,co.to no avail.
My next move, thanks to you is to contact my ststes Ins . Commisioner. I cant wait to spend all day on the phone tommorow. My doctor has deemed this med 'Medically Nessecary" and I will be sure to reinforce that to them over and over.
Thank you sooo much for your expertice. And your kindness.

Title: Re: Fentora [Fentanyl Citrate]
Post by UN solved on May 11^th, 2007, 12:28am

So this is different from the Actiq lollipops ? In what way ? Stronger, Weaker, Faster ? Is it a totally different drug than what is in Actiq ( Fentanyl ) ? I have not seen or heard of this drug before now.

UNsolved

PS. You'll get hooked on this drug (Fentanyl) pretty quick and this is a deadly drug if not used properly. plz use caution and think carefully weather you want/need to start on this or not. Goodluck. Edited to add: I just re-read your last post and realized you've been on this for 6 months. I can't see them letting you take it for 6 months and then pulling the plug. Again, goodluck.