When medicare/Rx refuses to pay for drugs

For discussing ostomies that are intended to be temporary, and the reversal/takedown of such ostomies.
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Doris+
Posts: 49
Joined: 2014-12-16 09:39:45

When medicare/Rx refuses to pay for drugs

Post by Doris+ »

I had a total colectomy with ileostomy 7 years ago. After numerous problems, primarily a huge hernia and several obstructions, a new, progressive surgeon recommended a reversal to be managed with drugs. It was difficult but worked (most of the time). With 3 prescriptions, including tincture of opium I was able to control my movement most of the time. No complications. I'm healthy and functioning. Now medicare/Rx refuses to pay for the tincture of opium. At $600 a month I can't purchase it myself. I can no longer control my diarrhea. Next week I go to the surgeon to talk about surgery for another ostomy. I understand the expense, I pay half. What I don't understand is why they would prefer to pay the expenses (including complications) of an ostomy rather than pay for the Rx. I understand I can file for a review. The surgeon doesn't hold much hope. She's seen it before.
Please understand, I'm NOT telling people not to have a revision. It works great for most people and drugs help many with problems. I guess I'm letting of steam. I thought managed care was for the benefit of the patient. I was wrong.
BillV
Posts: 120
Joined: 2013-11-11 21:24:03

Re: When medicare/Rx refuses to pay for drugs

Post by BillV »

It is indeed unfortunate when an insurance company (Medicare/Rx in your case) decides to “play doctor” with your medications. Many of the clerks making these initial determinations have little, if any, medical background. The one who denied your prescription for an opiate likely had the mindset that this kind of medication is used for pain control, not control of motility. Obtaining approval for “off label” use of a medication can be a great, but not unsurmountable, challenge. Before undergoing a surgery that you do not want, I would encourage you to have your doctor submit a carefully worded appeal stating that other (less expensive) medications have not been effective in controlling your motility like the tincture of opium has done and that denial of this medication will make a costly and undesirable surgery necessary. Put up a fight for your quality of life, and best of luck.
Albion
Posts: 1
Joined: 2017-03-19 14:20:57

Re: When medicare/Rx refuses to pay for drugs

Post by Albion »

I'm sorry you have to endure this. Tincture of opium is a valuable drug, and it should be made available for people who need it. There are at least two cases of Medicare patients appealing successfully to have tincture of opium covered. If you search for "opium" at the HHS link here (https://www.hhs.gov/about/agencies/dab/ ... index.html), you can read the decisions.

In the meantime, you might ask your doctor to try codeine sulfate tablets, which are relatively cheap (120 tablets of 60mg codeine sulfate is about $50 at Walgreens, and probably less at Costco). The doctor might also be willing to prescribe liquid morphine (which is very similar to opium tincture). It's about $13 a bottle, as opposed to $600 for opium tincture.

As a last resort, you could try a compounding pharmacy. They can make opium tincture by dissolving opium powder in alcohol. Powdered opium is very inexpensive (they can order it from their supplier; it's manufactured by Mallinckrodt Pharmaceuticals). The link to the product description is here: https://www.google.com/url?sa=t&rct=j&q ... hu_e-86fWg

The last time I checked, they could compound a bottle for about $50, which is better than $600 for sure.
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