October 7, 2007

This Is What You Wanted, Right?

Remember all those articles about bipolar needing specific treatments, and that you should never use an antidepressant? 

I have a guy on Zyprexa and I add Lexapro, patient comes back the next day and says the insurance wouldn't cover Lexapro, and hands me an insurance rejection which says exactly this, punctuation included:


Clinical Review Third Party Override Required.  Prescription had the following Clinical Review message(s)- "Lexapro Oral Tablet 10MG should be used with extreme caution in Bipolar Mood Disorder, which is a proxy medical condition based on the use of Zyprexa Oral Tablet 5MG." and "USE FLUOXETINE PAROXETINE SERTRALINE CITALOPRAM"


In case you're missing the beautiful irony, let me extrapolate the rejection's four points:

  1. Didn't you psychiatrists all agree that antipsychotics are "anti-psychotics" and thus only for bipolar or psychosis?  We assume you are rigorous, therefore this must be a bipolar patient.
  2. Didn't you psychiatrists all agree antidepressants, like Lexapro, were dangerous in bipolars? 
  3. Fortunately, we at the insurance company caught your oversight before it was too late; disaster averted.  No need to thank us, your silence is sufficient.
  4. Oh, and BTW, if you ever do want to use Lexapro, don't-- please use these generics, which are ipso facto safe in bipolar, as they are generics. 

It's only a matter of time before the insurance company adds:

  • You know, this is pretty easy; the meds do all the work, and we have to catch your mistakes anyway.  So, we're going to reduce the Medicaid payment for office visits to, I don't know, $35 for an office visit. Oh, wait, we do that already!  BWAHAHAHAHAHAHAHA!  We'll just get the primary doc to do it.

You're going to say, no, that'll never happen.  Oh yeah?  Did you expect this to happen? 




Becasuse of course some cle... (Below threshold)

October 9, 2007 12:21 PM | Posted by Jennifer Emick: | Reply

Becasuse of course some clerk at the insurance company knows better than the doctor!

Alone's response: Well, here's the problem-- tell me why, in this rejection, the clerk is wrong? In other words, what maxim is the doctor operating on-- beyond "it's just a feeling"-- that supersedes the protocol that psychiatriy has established, which is what the clerk is using?

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Isn't it already happening?... (Below threshold)

October 9, 2007 12:51 PM | Posted by Lexi: | Reply

Isn't it already happening? That GPs are giving out perscriptions for psychotropics? I'm pretty sure that is already happening.

My dermatologist offered me wellbutrin. the DERMATOLOGIST and WELLBUTRIN!!!! Um WTF? I said no.

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PS-- yes the derma isn't my... (Below threshold)

October 9, 2007 12:54 PM | Posted by Lexi: | Reply

PS-- yes the derma isn't my primary Doc, but I have stories from friends that get stuff at their GPs . . . >sigh

Alone's response: and from the PA, and online, and friends, etc, etc. In other words...

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I'd interested in your take... (Below threshold)

October 9, 2007 2:24 PM | Posted by Steve: | Reply

I'd interested in your take on the CATIE results. As I understand them, we're better off with the old generation meds.

Along those lines, would you say that the evidence supports use of lithium bipolar disorder over other therapies?

Alone's response: what kind of a psych blog would this be without a post on Catie? I did two-- search in box. Summary: a) confirmed what we already know, that all antipsychotics have equal efficacy-- WHICH IS GUARANTEED BY GOD HIMSELF SINCE THEY ALL WORK THROUGH THE EXACT SAME MECHANISM; b) they differ in tolerability. The rest of the study is an exercise in sleight of hand.

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Two stories from the front:... (Below threshold)

October 9, 2007 3:26 PM | Posted by AK: | Reply

Two stories from the front:

I was told that Effexor could be helpful in reducing hot flashes. Knowing what I know about the difficulties of weaning from the stuff, I said no thanks.

A friend with ghastly insomnia and who fears addiction due to family history was offered Trazadone as a sleep aid. In her case, one tablet generated nasty side effects which included insomnia, tachycardia and heart palpitations.

She returned the bottle to the pharmacy and is seeking to verify that the stuff was only prescribed for insomnia, not for depression.

('Yeah I am depressed,' she snarled. 'When I get 4 hours or less sleep per night I feel like shit. When I get enough sleep, I am happy!)

To add insult to injury, those GPs who prescribe antidepressants may not be aware but if you're RX'd antidepressants some asshole insurance company may use it as an excuse to deny you coverage due to a pre-existing condition (depression) or raise your rates.

Properly prescribed, antidepressants do save lives. But...your average harassed GP or nurse practitioner isnt going to know enough about them to assess whether they're actually the treatment of choice.

But the insurance companies and HMOs are cheapskates. They want to save bucks by having the GP do everything, rather than do the right thing and make a referral to a prescribing psychiatrist.

And..that is assuming the prescribing psychiatrist knows how to prescribe the stuff and isnt being unduly influenced by drug company propaganda.

It is a jungle out there.

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You hit the nail right on t... (Below threshold)

October 10, 2007 7:50 AM | Posted by dnaphreak: | Reply

You hit the nail right on the head. Although I believe point four should read...please use these generics, which are ipso facto much more profitable for us, as they are generics.

Alone's response: you're point is a good one, but the one I was going for is the anal rape of logic that psychiatry uses to recommend/discourage one type of treatment that is now being commandeered by insurance companies to use against it. As in "we know you said blue is bad, so we recommend you instead use these other pills, which are safer, and also blue." Makes no sense? Exactly.

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10mg lexapro on top of 5mg ... (Below threshold)

October 13, 2007 6:26 PM | Posted by acute mania: | Reply

10mg lexapro on top of 5mg zyprexa. I thought you didn't agree with polypharmacy (i.e. there's no reliable evidence to support it) and 5mg zyprexa according to you is below the threshold needed for work as an antipsychotic. And lexapro isn't equal to celxwa at 4 times the dose.

Alone's response: well, I'm not completely opposed to polypharmacy-- does two meds count as "poly?" What I was opposed to was two meds with the same mechanism used simultaneously. In this case, I wasn't using zyprexa as an antipsychotic at all, hence the low dose. What matters is that nominally I was using an "atypical antipsychotic" and so much was inferred by the insurance that was not implied by my choice.

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Hmmm....well perhaps the in... (Below threshold)

October 23, 2007 10:20 PM | Posted by Carrie: | Reply

Hmmm....well perhaps the insurance company could misinterpret. While obviously not your scenario, it could theoretically be a migraine patient prescribed 5mg zyprexa as an abortive and taking lexapro for depression.

I like to think outside the box. :)

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