Old 04-23-2015, 10:05 PM #1
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Default Health Insurance denying Cymbalta

So. . I received this super ****ing awesome notice from my insurance company that says:

"We have received a request to review the medication Duloxetine Hcl. However, at this time we do not have enough clinical information regarding your health status to determine medical necessity.

If you and your provider decide to continue with the treatment, we cannot guarantee your benefits will be covered.

If we receive the necessary information within the next 48 hours, we will review this request for benefits. If we do not receive the information within 48 hours, we will make a determination based solely on the information that we have available."

This was mailed to me on the 20th and I didn't receive it until today. What the ****ing hell am I supposed to do?
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Old 04-23-2015, 11:11 PM #2
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Default Re: Health Insurance denying Cymbalta

You'll have to make some calls to insurance and Dr. Explain the bad timing of delivery, get your Dr. or asst. call them. You may have to go back and forth a bit. sorry for your frustration. I would think it's ultimately your Dr.s responsibility to give the info. in the first place. And remember, diplomacy! Even if you'd like to strangle them all. Good luck!
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Old 04-24-2015, 07:33 AM #3
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Default Re: Health Insurance denying Cymbalta

Ruralchick gave excellent advise. You doc will need to give the diagnosis to the insurance company for the prescription. Try to get your doctor to give you 6-12 refills in case the insurance company balks again. It is likely that your doctor will need to submit need again in one year. Insurance companies think they know more about medicine than doctors. Good luck!
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Old 04-24-2015, 09:58 AM #4
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Default Re: Health Insurance denying Cymbalta

As far as I know he's already done all this. They've been denying me Cymbalta since February and I had to switch to Effexor. But Effexor gave me too many of the side effects and I couldn't function on it, so he told me to stop and we've been fighting with insurance the last 3 weeks to get back on Cymbalta. It's infuriating.
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Old 04-24-2015, 11:18 AM #5
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Default Re: Health Insurance denying Cymbalta

Tell the stupid insurance company to read the research! Though I'm sure they would not. Cymbalta is one of only three meds approved by the FDA for fibromyalgia. It is infuriating when they're denying something your doctor recommends. My mom and I fight all the time with my parent's insurance company. So far, my current insurance hasn't given me any big hassles.
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Old 04-24-2015, 01:18 PM #6
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Default Re: Health Insurance denying Cymbalta

I'm on the generic of cymbalta, otherwise I would have to pay out of pocket, it's called duloxetine. What insurance do you have? Sorry that's nosey, I have a family member that's on a government insurance and it takes Forever for him to get even a diagnoses.,
Ps, (also I beleave he has fibro too, and my brothers and sister,, my family comes from the UK origanally, I've taken sit that there is a large percentage of sufferer from the uk.
Anyone else pick up on that?
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Old 04-26-2015, 04:05 PM #7
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Default Re: Health Insurance denying Cymbalta

im sorry you are going through that.

i would ask the insurance to mail you what they are reviewing and making their decision based on. sometimes like i learned when i was in the hospital. doctors lie! have your doctors office confrere to in on a phone call to the insurance company. mosylt wshey an insurance as they are not covering a med any longer they list a few meds like it that they do cover. try asking that question too.

i hope this helps you and you get some relief soon.
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Old 04-26-2015, 07:47 PM #8
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Default Re: Health Insurance denying Cymbalta

Thank you for the support everyone. . I really appreciate it.

My Insurance won't approve either Cymbalta or Duloxetine so it's been super horrible. I have Anthem Blue Cross Blue Shield Silver.


Why are Insurance companies so brutal when people need these medications? I don't understand them at all.
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Old 04-27-2015, 02:31 PM #9
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Default Re: Health Insurance denying Cymbalta

i have the same insurance and they cover my meds. when they dont cover a med they send me a letter that says they dont cover that,
but do cover this.

it really sounds like your doctor is not sending them what they need to know. it's pretty clear in the letter you received from BCBS.

if they (insurance) dont know what the doctor is doing, then they cant give you meds that are dangerous for you.
They are watching out for you there.

Believe me, the insurance company is watching out for you. i have had many meds stopped and i have even had my morphine increased
by bcbs. they told my pain mgt that im not on enough morphine to get the subsys med. so she increased it.

call your doctor, go pick up copies of what he sent to the insurance. then call the BCBS nurse line and review it with them.
this is a good starting point for you.
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Old 04-28-2015, 06:40 AM #10
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Default Re: Health Insurance denying Cymbalta

Something else to know about insurance companies: they will sometimes deny a drug that's expensive, like Cymbalta or its generic equivalent out of hand. Just due to cost. If you were on Cymbalta previously and it was working, that's a good argument for you and your doctor to pursue. They can pay for more physician bills and ER pill or pony up for the medication that was working. I pay a higher co-pay for Cymbalta each month with my insurance but it's worth every extra penny for me.
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