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Having problems getting insurance to pay for meds

sonofjorelssonofjorel Posts: 5
edited 06/11/2012 - 8:21 AM in Pain Medications

I have been having problems getting my insurance to pay for Lyrica. Has anyone had any problems getting this med?

My Dr. prescribed it to me last Thursday but the Pharmacy can't get approval. My doctors office said they called the insurance to get the approval but it was declined. I don't know what is going on but have never had any issues with getting meds.

I have tried Neurontin, tons of different muscle relaxers, and narcotics and have not had any issue. I don't know if it is because it is a new and maybe expensive or what.

If anyone has run into this or can give me some info on what to try next that would be appreciated. I have a herniated disc at L4-L5, narrowing of my spine which pinches nerves. Also had 6 nerves burned off as well in my low back so I was hoping to get some help from this drug. I have read sometimes it helps sometimes it doesn't but am willing to try anything.

Thanks again,



  • If they've denied the claim, a letter won't help - your doctor has already been through the prior authorization process. Unfortunately, I'm afraid there's nothing you can do, short of paying out of pocket or changing insurance companies as soon as your open enrollment time period begins (if you have the option to pick a different HMO). You could also try to get patient assistance from the manufacturer, but there are severe income restrictions, and people rarely qualify.

    I work in a pharmacy - what happened to you is called needing a prior authorization. Lyrica is one of the most common drugs needing to go through this process. Celebrex is another. Unforutunately, once it is denied it is denied. I wouldn't make my doctor's office do any more work - your insurance won't budge.

    I'm not trying to be negative, I just see this every day. So sorry that this happened to you. I would send a letter to the insurance asking them to change their policies. It won't help, but you may be able to open someone's eyes and maybe they could put the drug under review when they look at next year's formularies, if they haven't already. Also, different "groups" have different formularies. Your Blue Cross Blue Shield may cover different things than someone else who's under the same plan but administered by a different group - it depends on your employer as well as the insurance company.

    I know, it's way more complicated than it should be, but America's insurance is still better than those that have universal coverage and have to wait a year for an MRI, for example. So in some ways we should count our blessings.

    BTW, Lyrica isn't covered for me, either. Neither is Celebrex. Neither are Opana or Kadian. As long as there is something therapeutically equivalent (not nec. generic, but something that works similarly), insurance feels no need to cover expensive name brands.
  • I posted earlier this morning on the snake oil/lyrica post....I just found out that my new insurance will not cover Lyrica....this drug has helped me so much and now I am scared to death. What is the difference in neurontin and lyrica??? I remember right after surgery the doctor put me no neurontin and it did not work, my nerve pain of course was at a 10 plus, they switched me to Lyrica and it seem to work better. I'm just wondering now if the neurontin will work as the nerve pain is not as bad as right after surgery.

  • Thanks for the responses. I guess I will have to live with it. I don't really want to take the Neurontin again I was at 2400mg and I think the max is 3400 or 3600 mg. I don't know if I could take that again. My Doctor was trying something else to see if they could do anything.

    Thanks Again,

  • I recently had my prescription for Lyrica denied also. I had been taking it for a year and a half. It worked very well for me. They suggested I try the gabapentin to see if it was as effective. I just started it about a week ago. It has helped with with the nerve pain and I have not had any side effects. Hopefully it will hold for me. I was pretty upset about the denial... I thought if my doctor would have wanted me to be on the gabapentin, that's what he would have prescribed to begin with!
  • Is that why I can't remember anything??? I never thought about the Lyrica causing it. Not that I have anything great to remember but pain and doctor appointments....I have to write everything down and have thought about putting post it notes on my body.

  • Nflmdslh0etNNflmdslh0et Posts: 1
    edited 10/13/2015 - 9:10 AM
    I have prior authorization, as well as a prescription for Lyrica, however my insurance company is still denying the claim.
    On the letter it says "Prescription has been denied for reason(s) stated below."
    However it doesn't actually have a reason stated on the letter.

    Is there any type of legal action I can take to rectify this situation?
  • SavageSavage United StatesPosts: 5,427
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