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Topic peer to peer review req'd for routine rx? Go to previous topic Go to next topic Go to higher level

By lurkingforacure On 2009.09.30 11:01
Sorry I will make this as brief as husband has been taking mirapex since getting dx'd almost four years ago. Never a problem getting the script filled.

Last week I went to refill the was denied. Our pharmacist said our neuro had to fill out some form to send to the insurance company (I think the script was older than a year, even though we had refills still on it, and it had to be renewed), so he did that, and it was denied again.

When I talked to the pharmacy dept. of our insurance company, the gal told me that mirapex was no longer "automatically covered" and that to get it our neuro would actually have to have a peer to peer consultation with their inhouse medical guy. I am livid. why? We have been on this drug for years, it's not new, our condition has not gone away (wish, wish) and we still need it. It's like telling a diabetic that their insulin is no longer covered without a time-consuming peer to peer consult by the doc.

The only thing I can think of is the lawsuits involving mirapex? Maybe the insurance company wants to be sure they don't have someone continuing to get mirapex if it is causing them some of the problems we've all read about (in other words, they dont' want to bear any responsibility/liability in such a case)? I just have never heard of such an absurd situation. No doubt there's a lawyer behind it :) Anyone ever had this happen, and what did you do?

By caregivermary On 2009.09.30 11:56
I haven't heard of this happening. I talk with a lot of people using mirapex and requip and no one has mentioned it. Sounds like the insurance company is getting between the Dr. and the patient.

By bandido1 On 2009.09.30 12:01
Lurking: your post demands a quick turnaround so I will keep it short. Call your neurologist again and demand the so called"peer" conference. Hopefully you have enough medication to last a few more days. I suspect your neuro will prescribe Rquip or RequipXL as a replacement. Given the circumstances, I see no reason why the insurance company, your pharmacist and the Dr. cannot coordinate a quick solution to this problem. Good luck! Bob C

By LOHENGR1N On 2009.09.30 16:06
Lurking, I've had similar situations with med's. Where the Neurologist prescribed a medicine and was informed that the drug wouldn't be covered (in fact it was one I was taking at the time) because other drugs on the market were cheaper or had cheaper generic brands that were used for the same purpose. (the fact that they were inferior or didn't work as well didn't matter to the insurance!) My Neurologist was livid, and told I would have to try all the other brands on the market before the medicine would be considered for coverage! But then I live in Massachusetts where for years now the practice of medicine has been taken away from the Doctors and placed in the hands of the insurance companies. Our Commonwealths legislative body mandated any and all prescriptions written be filled with generic equivalents if available! To get name brands the Doctor must specify such and then be questioned or reviewed. (Which reading between the lines means too many pricey prescriptions and referrals will drop.)

In my opinion the state senators and representatives mostly with backgrounds in law (inept in their chosen field else they would still be practicing), have somehow gained medical degrees and know more about medicine than the specialists in medicine who've dedicated their lives to the field.

Like on top of everything else We need to deal with this right? Take care, best of luck and hang in there.

By WitsEnd On 2009.09.30 16:46
Unfortunately the insurance companies have their "formularies". These are a list of drugs they have decided you can take. For instance Medicare didn't cover Lunestra for dad's terminal insomina. They provided generic Ambien...take it....or pay full price for Lunestra. Different insurance companies have different formularies. Your only choice is to shop insurers if you can, accept something else....or pay it out of pocket.

By shakydog On 2009.09.30 23:17
Hmmmm. Sounds like we are loosing control of our insurance companies. Like there isn't much of a difference between mirapex and generic requip. Or just taking sinemet by itself.

Sinemet works for most of the symptoms and the side effects aren't that bad. Why do you need that expensive mirapex? That is the attitude of the insurance companies. What is next? How much longer will you be covered?

I'm sorry this post is going to slide into the "non-pd" side.

When your insurance company can question a script for a valid treatment, how much longer will they continue coverage? Then you can try getting insurance in the current market.

In a perfect world, insurance reform would mean that we didn't have to worry when the refill day comes around. Like we all do now.


By lurkingforacure On 2009.10.01 18:37
update: I got a letter from the insurance company today informing us the denial was based on the fact that we must, repeat MUST try requip first, and if that is not effective, then they will reconsider. What a nightmare...I remember we had to go through this with the sinemet, they tried to get us to use the generic which my husband might as well have taken a jelly bean for all the good it did, and we finally got the name brand. But to put a parkie through this is absurd.

I guess we will have to "try" the requip, maybe it will work, maybe not, and see. My guess is it won't work, my husband will have a horrible time going through it, and we'll be back to where we should have been all along. Love it.

By susger8 On 2009.10.02 07:49
Requip and Mirapex work through the same mechanism and are pretty similar, so maybe you'll be lucky and Requip will work for your husband. I'll cross my fingers for you.

By dkleinert On 2009.10.03 00:58
My husband had to stop Requip after about 6 months because of the awful auditory and visual hallucinations. He was put on Mirapex and Sinemet - no hallucinations with those. Poor guy - he thought he was losing his mind, and finally told me about all the visitors he had all the time and the voices he heard, we talked to the doc and asked to be changed. So far, he is still taking those.....Is Medco your insurance's provider for Rx's or someone else? THANKS for posting this - hope this is not a small picture of things to come.....

By lurkingforacure On 2009.10.03 10:59
We have Humana but I think most insurers are the same. Interestingly, the nurse told me yesterday we had already tried Requip and it didn't work for my husband, made him sick. I don't remember that but three years is a long time and I can barely remember when to pick up which kid from which activity most days anyway, so that doesn't surprise me that I'm losing my memory!

I have to fill out a form asking for an appeal and then they will make their decision. In the meantime, we are getting some samples from the doc so my husband doesn't get in a bind. I guess that's one tip I can offer: always ask for samples from the doc's office in you find yourself in a position like this. Sometimes they have them, sometimes they don't, but you should always ask.

By mytngenes On 2009.11.04 22:05
We went through the same thing with my husband. He's been on Mirapex since first being dx'd in 1998. Because he is on disability, we took the Medicare Part D (prescription drugs) when it became available. Mirapex was covered the first 2 yrs, but last year we got the notice that it was not on the formulary for Humana. Our dr appealed 3 times and we were denied 3 times. I shopped around for other Medicare Part D insurance providers only to be told the same thing. That's because the formularies are federally mandated. None of the Medicare insurance providers will pay for Mirapex. They will pay for Requip, but not Mirapex. I'm thinking the same thing--its because of the costs of the litigation against Mirapex.

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