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HOT INFO - Pain Medication Change January 1 2018 - anyone else heard this?

hey all - so i got some information today that requires further explanation. I was getting my break through medication filled today, II get 120 a month, I also get 90 Long acting meds a month, both which don’t control my pain now.... My problem, the insurance rejected paying for the script due to quantity. I’ve been on the same quantity of pills for roughly the last 5-6 years and actually have come down from 180 at the highest point. I go to a small mom & pop pharmacy and according to the owner as of 1/1/18 insurance companies will no longer pay for more than 60 short acting pills a month. I was also told Long acting will be restricted to 90 pills a month. What is scaring him, if a pharmacy does fill more than 60 pills a month that pharmacy will get a visit from the DEA., my pharmacy is in MCLean, Virginia and the DEA is around the corner also. Now can anyone elaborate or clarify if this is correcr? Or can anyone explain it in further detail? I’m trying to contain my feelings OUTRAGE regarding this until I have All the details. Thanks for ready my post and I look forward to all your replies.




  • I think you have your wires crossed. Long-acting would be limited to 60 a month. And short-acting to 90.

    This isn’t surprising since I don’t think there’s a long-acting (ER) medication on the market that’s intended to be taken more than twice per day (30 x 2 = 60 for the month) anyway.

    Your only beef would be the limitation to 90 for short-acting. It’s probably part psychological on the insurance company, rather than a financial issue. Dispensing opioids in double-digit quantity doesn’t seem as damning compared to triple digit (100 or more) quantity.

  • Bldbeaner, Here in Florida their also changing the amounts they can give as well! It’s so bad my pain management MD closed office 3 weeks ago and moved up to NC!

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  • in 2018 my insurance will allow 3 extended release pills/day and 4 immediate release/day

    in 2017 it is 3 er and 6 ir...so they went from allowing 6 immediate release to 4 for next year

  • The user and all related content has been deleted.
  • memerainboltmemerainbolt IndianaPosts: 3,437

    If I'm not mistaken, it's going to depend on your state regulations as well as your insurance carrier.

    Spine-Health Moderator
    Please read my Medical History
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  • peanut006peanut006 MichiganPosts: 6

    I believe you're right @memerainbolt... and just to add to that, I believe that in most cases your doctor can request prior authorization with most insurance carriers to go above/outside insurance guidelines as long as the have justified documented reasons to... at leat that's what I've seen in my experiece. But obviously each individual situation may be different.

  • L4-L5- no I actually received a printout from my pharmacy on the medication and it was the only script I was filling. I ended needing to pay cash for it instead of using insurance.

    Davidg- that stinks, my doc has offices in MD& VA so I may just need to start filling my meds in MD instead of VA.

    scinmyheart- thank you for that info, that may be the case.

    Sandra, rll54 & peanut006 - thank you for he info, next month I will have Medicaid so I’m not sure what the difference will be. Hopefully it will just be to need prior authorization.

    The other issue, my pharmacy is overly cautious due to having an issue 17 years ago with a physician that was over prescribing meds and got involved in the case. There is a movie on Netflix about the doctor. Thank you all for the info.

  • Yep, that's due to Quantity Limits. All insurance companies have them and if you look at your formulary for the year, on the right hand side it will say QL on any drug which has them. The insurance I have had for the last 3 years actually has very few quantity limits and on all but one of the long acting narcotics, allows 3 or 4 per day depending on which one you are looking at. I expect that may change at any point so before signing up for insurance again for the year always look at the new formulary because it may have changed from the previous year. Don't feel bad, Oxycontin caused me to be in the doughnut hole this month and my meds cost me $230.00 instead of the usual $30.00. And it had to happen at Christmas time! And as far the the QL's go, your doctor can always request that the insurance company pay for the overage if he justifies your need for them. Best of luck.


  • dilaurodilauro ConnecticutPosts: 11,638

    There is so much being written today about what will be happening with opioids in 2018. I dont believe any final firm decision has been reached, at least by the Federal government. Each state does seem to have its own set of rules prepared for 2018.

    One crazy one I have heard came from CVS. Their plan was to limit opioids to being filled for 7 days at a time max! Sounds crazy, though they say you wlll have no problem getting the monthly required opioids, but it will be at 7 days at a time only.

    My take on all of this, is when it begins to happen, we will now the mechanics of any new policy. Until then there is too much speculation which can only get everyone running around in a frenzy, panicking or just mad.

    Ron DiLauro Veritas-Health Forums Manager
    I am not a medical professional. I comment on personal experiences
    You can email me at: [email protected]
  • Ron,

    If I understood the PA at my PM office last month, she thought CVS was already doing the 7 day limit which would make it very difficult for a PM office. She said to steer clear of them.

    I'm like you, it just doesn't pay to speculate and worry about something that may or may not happen. In fact one of my favorite sayings is:

    Worrying does not empty tomorrow of its troubles, it empties today of its Strength.

    Hopefully common sense will prevail.


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