DrugBuyers.Com: Has this happened to you?.........

Due to chronic back pain, I have been taking about 200-250 mg of oxycontin on a daily basis. Now just to be completely clear here, 40 mg of that 200-250 comes in the form of 5mg oxcodone pills. These are spread throughout the day and are primarly used for breakthrough pain as well an attempt to keep the level of pain meds at an even keel as the hours pass. The reason I listed my daily dose at 200-250 is because up until last Friday(Jan 23)I was taking 255 mg daily,(keep in mind I had been as high as 320 mg daily at one point... but that was several months ago). Then as I mentioned above, on Friday Jan 23 my dose(s) were decreased down to 200mg.

I have been using Oxycontin for pain management for nearly a year now. Before that I had been on just about every other pain med under the sun. Until being put on Oxycontin, I was in far more constant pain than anyone out there should have to be in. It is not a pleasant thing and I wish that level of pain not even on my worst enemies (OK well, maybe on a few of them. HA, J/K)

So, directly before making the switch to Oxy I was given the Duragesic (sp) patches try out. I can not remember the exact dose of the duragesic, but I do remember the pharmacist saying it was one of the higher ones he has seen. Whatever. All I know is I had some sort of allergic reaction to either the med or the sticky stuff on the patch that was there to keep the patch on my body for 3 days. The rash got so bad that I had to stop using it immediately. Plus to be completely honest, the duragesic patches seemed near useless in it's attempt to decrease my level of pain. I really do not think that it was not working for me because of too low of a dose, or not giving it enough time to get into my bloodstream at any even and steady level because as I said, i was prescribed a high dose, and even with the awful rash, i kept trying to use them as I was willing to live with a rash if I was able to JUST STOP THIS HORRIFIC
I sort of remember that every three days my husband was constantly trying to find an area on my body not consumed with welts or itchey, burning rashes so he could find space for at least 2 of the 100 patches on, along side a few of the smaller ones. (I am really no sure, but I could have sworn that there were 3-100 patches used ever 3 days. But I could be wrong. Either way, I was told it was a relatively high amount to be using.

Initially i was excited as I had read so much here at DB about what some mebers said to be "their miracle pain medication....Duragesic" Well, as I said, nope, no miracle here.

OK now to the question I posted in the subject matter.

HOW IS IT POSSIBLE THAT WHEN I AM TAKING SUCH A HIGH DOSE OF OXYCONTIN AND OXYCODONE, AS WELL AS ALL OF THE OTHER PAIN MEDS MY DOCTORS HAVE ATTEMPTED TO GIVE ME BEFORE STTLEING ON THE OXY, DO I STILL GET A STRANGE "BUZZ" WHEN I TAKE MY MEDS IN CONJUNCTION WITH 1-3 FIORICET'S W/CODEINE (not sure on the spelling of the Fioricet there. But just to be clear, it's the one that has apap, not asprin, as I am allergic to asprin).

Yep, you heard it, I take a lot of the opiates each day and I have NEVER, and I mean NEEEEEEEEEVER had any sort of buzz after taking them. And I mean not even when I end up taking a higher dose at one time, and not as spread out as I normally take it. I sometimes have to do it like that if I either have gone far to long inbetween doses, or if I have a particularly terrible nights sleep and any attempts to get out of my bed are nothing more than failed attempts. Only then do I take a bit more of my daily dose at one time, but I then just make up for that later in the day and take less at the time for my second dose.

So basically I do not get light headed at all, no matter how much I take, and that has been the case almost from the start of my being prescribed the oxycontin for pain. But this phenomenon is not only with the oxycontin. Oh no! This seemed to happen with the percocet, MS Contin, Vicodin and several other meds that I ended up being prescribed several months before the Oxycontin. Those meds did not give me a "buzz" but they also did not help with the pain. I did not have any kind of relief from the pain until they put me on the oxy.

I used to get that "opiate feeling" if you will, when I first started taking pain meds prior to even being completely diagnosed w/herniated disks. My first doctor prescribed darvocet, vicodin, T3 and some of the other mild meds when I was getting migraines. Actually that was how I discovered the Fioricet w/codeine.

But now, no matter how much I am taking of the other stuff, when I take the Fioricet (still prescribed to me for headaches but i tend to take them along with my oxy daily doses in the hopes of cutting down on the number of 5mg oxycodones I take).

However immediately after taking the fioricet after several months of not taking it, I go the kind of feeling i used to get when I first started taking the darvocet and 5mg vicondin, etc. Except this time it did not go away. How is this possible? I mean it is not as though this buzz or happy feeling stays for a long time after taking the fioricet, but long enough to secretly wish that the oxycontin/oxycodone had a similar effect (but thats my own little private secret, I would never dream of telling my doctor that. Plus, I would give the happy feeling up in a minute if i found out I was not able to get the pain relief i now get from the oxy's. I am still not out of pain totally, but hey, even 30-60% pain reduction is better than nothing.

Now, with the happy feeling I get from the fioricet. It soon fades (sadly) but the funny thing is it still happens every day I take it. As though i am nopt building a tolerance. How is that possible? Too bad the fioricet was not able to help all that much w/pain relief. I mean yes, it makes me feel giddy and light headed and happpy for a sghort time, but even with that phenomenon, I still feel the pain as if I took nothing at all. Well, I mena it is a bit dissipated, but no more so that had i just taken 4-5 Advil's.

Now, I know there are several meds inside the fioricet and before posing this question to all of you, I myself researched this weird occurance. I mean it can not be the caffeine as I have been a caffeine whore (excuse the potty mouth) for at least 10 years, and i am assuming that those nights that I studied straight through had me ingesting far more caffeine than the amount in a few fioricets. Also, the butabital (sp). I can not imagine that this is the reason for the buzz/high, whatever you want to call it. Then there is the apap. Um, need I say more?

OK, so even if all of the different meds in the fioricet have been known to give people a bit of an up, or a slight buzz. How on earth is it possible with the amount pain meds I have been on, for the amount of time i have been taking them, could I possibly continually have a physical reaction to just the fioricet, when it is no way as strong as the others?

I even thought that maybe this was happening because somehow mixing the oxycontin's and oxycodone's with the fioricet set off some chemical reaction, hence causing me to feel a buzz. So I did my own little scientific test. I briefly (and stupidly - -dont do this at home kids) started lowering my oxy doses so that i was down by more than 50% my normal dose. Well beside feeling much more pain, but suprisingly not as much withdrawl as I anticipated, I once agaion took the fioricet. Well, immediately I felt that same ole' warm and fuzzy feeling and was once again stumped by the powerful nature of this pill.

I have tried several other "scientific tests" in attempt to figure out why I react so strangly to fioricet and no matter what I did, I ultimately still had the same lovely phenomenon. Of course I must say, because I was prescribed the fioricet for headaches, I was unable to continue taking them all of the time. Which at this point I would have to consder a good thing. Also another negative is it does seem that I have built up a bit of a tolerance to the fioricet. Far quicker than w/the oxycontin and oxycodone.

So now if I do take it for breakthrough pain, or for the headaches, I need to take 2-3 if I wasnt any results as all. And when I say results I am in no way saying I am searching for a result that consists of a "high". Know, the fioricet does work for my headaches when almost nothing else will even tough it. As I also said, it does not alot of good for the back pain, but what relief it did give, was no longer happening when I was taking the minimal dose of it. Meaning like 1 pill.

Now, I know this is really long, especially considering i only had a quite teeny tiny question. But once again, my defense to this posts' length is simple, I find background info necessary in anything I read, so I follow these guidelines when I myself post any questions or comments. I do this even though I assume most of you want to vomit when you pop open my question and realize it was nothing more a trap. Sorry.

Any input on this little fioricet happy feeling phenomenon would be greatly appreciated! Thanks

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Flea

I can't speak to the specific policies of the particular insurance company for which your friend works, but I can unequivocally state that this does not generally apply to insured prescriptions.

What your friend described would require the manual intervention and review of each prescription claim before granting payment authorization. Because more than 90% of dispensed prescription in the U.S. are insurance subsidized, the only practical means of doing so is through automated claims adjudication (sometimes known as online third-party processing) which is an instantaneous process that occurs through the PMS (Pharmacy Management System) when the operator indicates that a prescription is dispensed, and has become a practical requirement before most pharmacies will agree to accept and submit claims for a particular insurance plan on behalf of its patients.

Gross profit margins have decreased so severely, especially for insured prescriptions, and labor costs have similarly increased, manually processing insurance claims for its patients is a practice that most pharmacies have simply chosen to avoid. They will still fill the prescription, but the patient must pay the full amount and independently submit a claim for documentation. In fact, it is so expensive for pharmacies to cope with automated claims that are computer-rejected, one of the major industry initiatives is to find a more efficient means of doing so without shifting the entire responsibility back upon the customer. To effectively sell an insurance plan, insurers have to demonstrate that it provides reasonable and accessible care to potential customers. This means it becomes very difficult to sell prescription insurance unless customers can fill their prescriptions at a wide variety of pharmacy locations, and doing so requires offering online claims submission and adjudication.

Plans that require manual claims processing are another matter and comprise a tiny minority of overall prescription insurance coverage. These plans typically service a specific demographic or health care market, such as high-risk groups or other specialized coverage for which it does not cover sufficient prescriptions to recover the cost of an automated adjudication infrastructure, and its members are likely to have few other insurance options.

The practice of initial claims denial was an unfortunate phenomenon that became a problem during the onset of managed care plans. HMOs had little regulatory oversight at the time; but that is no longer the case, and competitors offering legitimate coverage have proliferated in the marketplace and brought enough competitive pressure to bear which made the practice quickly disappear. If it occurs, it does so very rarely or among a very narrow and specific slice of the marketplace, and not for very long. Before accepting a plan, most pharmacies require very detailed information about an insurers claim process, including success, failure, intervention, and denial rates, as these are all costs a pharmacy must consider.

For example, the most pharmacy management systems architecture is based on a transaction fee for every claim submitted, whether it is successful or not. Some transmit directly to the insurer, but most transfer through companies called switches whose job it is to take the data, massage it, add a pinch of salt, and serve as a validation mediator between pharmacies and insurers. Each step of the process comes with a fee attached, and these can add up. One national pharmacy chain spends more than $1 million every year in claims transactions that are ultimately rejected by insurers. Most independent pharmacies subscribe to these services through either a buying group or local organization established to realize some economies of scale. Verifying the legitimacy of insurers is a serious business to pharmacies, and most contracts include provisions that allow pharmacies to recoup costs for excessive claim denials.

What the original poster is describing regarding Fioricet is most likely due to the plans formulary, which is a list of medications and rates at which the insurer will reimburse pharmacies for every FDA-approved prescription medication. Rates can vary from 0% to 100%; and plans that offer the best coverage are naturally the most expensive. Most insurers impose a formulary that provides one reimbursement rate or copay for generics, and a more expensive for the brand version of a drug if no generic exists. Most also limit coverage on some medications in certain drug classes, and some will only offer automatic coverage for specific medications within a class of drugs. Antibiotics and antihistamines are good examples, as prescribers tend to prescribe the newest, and most expensive, weapons in their arsenal. If there is comparable efficacy for a long-established and inexpensive medication, a plans formulary may favor them my offering full reimbursement for a limited number of them while offering lesser coverage, or none at all, for others. Most plans will eventually offer some level of coverage for all medications if a prescriber can offer a specific reason for choosing the more expensive alternative a given patient when that benefit may not be established for the public as a whole. Coverage for off-formulary medication may require pre-approval or special handling by the patient or pharmacy.

What doesnt quite reconcile is that Fioricet has long been available as an acknowledged effective migraine treatment and relatively inexpensive generics abound. Assuming that the prescriber is treating migraines, Fioricet would tend to enjoy a more preferred status on most formularies over Imitrex or other therapies that are both more expensive and have greater side-effect risk. Most plans do have quantity or frequency limits, and validly so. If they are constantly reimbursing for a medication when a more cost effective therapy may not have been explored, it certainly has the right to at least ask the question or require the prescriber to say so. This is all part of a highly-sophisticated DUR (Drug Utilization Review) model that is part of virtually every insurers practice.

It may be possible that the individuals prescription insurance is very poor or offers very limited coverage. If this is the case, its not the pharmacies fault, and the prescriber and insurer arent even to blame. The real argument is with the department or individual who chose to provide the plan to its employees. Pharmacies dont determine coverage eligibility, and Ive already explained why it is clearly not in pharmacies best interest when claims are denied. Prescribers are simply trying to provide the most effective treatment available while also trying to please the patient by providing a medication that is well-tolerated or familiar. Even the insurance providers, although they are fundamentally very sophisticated bookies by nature, base the amount and extent of the coverage they provide upon an agreed rate with the benefit manager, and I dont know of any insurance provider that doesnt offer multiple coverage options. The insurer must disclose the exact terms and type of coverage, and before signing a contract, the benefit manager is (or at least should have become) well aware of the impact to the employees it serves.

The best way to determine the specific reason for non-coverage is to contact the plan manager or benefits department and ask for the specific insurance policy, including the drug formulary. The insured is presumably receiving the insurance as part of an employment benefit and is therefore paying for the coverage. No party should resist providing the information, and Im sure the answer exists in the text. If the claim was inappropriately denied, I would ask why. Is the medication covered? Was the dosage too large? Does the plan only cover a specific days supply at a time? Did it require preauthorization before dispensing? Would it be covered if the prescriber provided appropriate documentation, and if so, what type of documentation is required? Is there an appeal process, as most states require by law? These are all valid questions but require assuming an active an informed role in ones own health care management.

In the end, the plan may simply not cover Fioricet, but it may cover a similar medication like Fiorinal. It may offer an alternative that is more effective, and if they are willing to pick up the tab, why not at least try it if studies have proved it to be more effective for the general public? The company may not have enough resources to provide a larger benefit for its employees, or there may have been a benefits manager who was either inexperienced or incompetent, and being able to educate them for the benefit of everyone in the organization is a wonderful opportunity in its own right. The bottom-line is that it is impossible to apply a realistic generalization for why this prescription was not covered at the time. Blaming the process as a whole does no good and neither does pointing a finger at pharmacies, insurers, or drug companies without understanding the relevant facts. At the very least, I can promise will be a very educational process. At most, it may result in better and more effective health care by learning how the process works, avoiding rejected claims, and knowing what is required to ensure the greatest possible coverage in the future.

I hope this helps.