Affordable ketamine & and the villainy of Medicare/Advantage
June 27, 2024 5:18 AM Subscribe
Hoping someone can help us in restoring/ensuring coverage or sourcing ongoing and affordable access to the two types of ketamine treatment (described below the fold) that have worked wonders for someone in the past.
Someone I care about (in the US) has been successfully treating chronic pain (primary) and treatment-resistant depression (secondary) with IV ketamine. They also use topical ketamine for the pain issue. Their income is very low. They have lost their commercial insurance coverage and are now on Medicare/Advantage.
The topical ketamine was being supplied by a compounding pharmacy. It has now been denied as outside the formulary. An appeal of that decision upheld the denial. Is there any recourse? (It seems unlikely; if I’m understanding correctly, Medicare – informed by the FDA’s stance? – does not “recognize” this as a legitimate use (damn them all to the deepest hell).)
So, are there reliable, trustworthy, and credible sources of affordable topical ketamine?
Regarding the IV ketamine. This treatment seems like it will be covered – at least for the time being – by one of the Advantage plans. However, that state of affairs seems quite precarious and the plans can change what they cover and what they deny even within a contract year (and damn them all as well to the deepest hell).
If they start denying the IV ketamine at some point, are there reliable, trustworthy, and credible sources of affordable ketamine to treat pain and/or depression? My understanding is that the dosage to treat pain is higher than that used for depression.
Remember, this person is on a very low income. A less-than-one-month supply of topical ketamine is over $600 cash price. A single treatment of IV ketamine is over $700 cash price at the current facility. These treatments have made a HUGE difference in person’s quality of life, and it really, really sucks that finances and an effed up healthcare system might take this away.
I hope there will be some good leads posted here, and also feel free to DM me.
Someone I care about (in the US) has been successfully treating chronic pain (primary) and treatment-resistant depression (secondary) with IV ketamine. They also use topical ketamine for the pain issue. Their income is very low. They have lost their commercial insurance coverage and are now on Medicare/Advantage.
The topical ketamine was being supplied by a compounding pharmacy. It has now been denied as outside the formulary. An appeal of that decision upheld the denial. Is there any recourse? (It seems unlikely; if I’m understanding correctly, Medicare – informed by the FDA’s stance? – does not “recognize” this as a legitimate use (damn them all to the deepest hell).)
So, are there reliable, trustworthy, and credible sources of affordable topical ketamine?
Regarding the IV ketamine. This treatment seems like it will be covered – at least for the time being – by one of the Advantage plans. However, that state of affairs seems quite precarious and the plans can change what they cover and what they deny even within a contract year (and damn them all as well to the deepest hell).
If they start denying the IV ketamine at some point, are there reliable, trustworthy, and credible sources of affordable ketamine to treat pain and/or depression? My understanding is that the dosage to treat pain is higher than that used for depression.
Remember, this person is on a very low income. A less-than-one-month supply of topical ketamine is over $600 cash price. A single treatment of IV ketamine is over $700 cash price at the current facility. These treatments have made a HUGE difference in person’s quality of life, and it really, really sucks that finances and an effed up healthcare system might take this away.
I hope there will be some good leads posted here, and also feel free to DM me.
Response by poster: To clarify, my questions are what's the most affordable cash pay source of these two types of treatment:
>>>TOPICAL KETAMINE
>>>KETAMINE DOSAGES TO TREAT PAIN*
* I only know of IV administration. I haven't heard of anyone in patient's large city doing IM (intra-muscular?) administration. Just read an article about a study using time-release tablets, but that's apparently not on the market yet.
Please stop posting information about trying to go through Medicare/Medicaid/Advantage. I was giving context/background FYI only. I do not believe there's any way to force these entities to cover these medications reliably and long-term. I have no spoons to help the person beyond two levels of appeals and denials. Not to mention the hundreds of hours I've devoted to helping them over the past few years.
FACTS:
(If you have proof otherwise, please give me a link.)
- Ketamine is not FDA approved to treat chronic pain -- only depression (and only via Spravato).
- The depression dosage is too low to treat pain.
- Medicare will not cover anything not FDA approved.
- Advantage plans will no cover anything Medicare doesn't.
- Advantage plans "stack" on top of Medicare. They can't deny coverage for something that Medicare covers, and they provide some additional benefits, such as reduced co-pays and OOPs. Maybe having to stay in a more limited network of providers is a poor trade off for some people, I don't know.
posted by concinnity at 7:18 AM on June 28
>>>TOPICAL KETAMINE
>>>KETAMINE DOSAGES TO TREAT PAIN*
* I only know of IV administration. I haven't heard of anyone in patient's large city doing IM (intra-muscular?) administration. Just read an article about a study using time-release tablets, but that's apparently not on the market yet.
Please stop posting information about trying to go through Medicare/Medicaid/Advantage. I was giving context/background FYI only. I do not believe there's any way to force these entities to cover these medications reliably and long-term. I have no spoons to help the person beyond two levels of appeals and denials. Not to mention the hundreds of hours I've devoted to helping them over the past few years.
FACTS:
(If you have proof otherwise, please give me a link.)
- Ketamine is not FDA approved to treat chronic pain -- only depression (and only via Spravato).
- The depression dosage is too low to treat pain.
- Medicare will not cover anything not FDA approved.
- Advantage plans will no cover anything Medicare doesn't.
- Advantage plans "stack" on top of Medicare. They can't deny coverage for something that Medicare covers, and they provide some additional benefits, such as reduced co-pays and OOPs. Maybe having to stay in a more limited network of providers is a poor trade off for some people, I don't know.
posted by concinnity at 7:18 AM on June 28
Mod note: Several comments removed. Please see OP's note above, they're asking very specific things.
posted by Brandon Blatcher (staff) at 7:27 AM on June 28
posted by Brandon Blatcher (staff) at 7:27 AM on June 28
Response by poster: Apologies, MeFi kindreds, if my frustration-fueled state allowed any sharpness to leak through in my follow-up post. I'm beyond overwhelmed by this state of affairs.
It's a special kind of hell to watch a loved one go through hell and be mostly powerless to help.
Time for a little break of coffee, breakfast, and some deep breathing.
posted by concinnity at 7:40 AM on June 28
It's a special kind of hell to watch a loved one go through hell and be mostly powerless to help.
Time for a little break of coffee, breakfast, and some deep breathing.
posted by concinnity at 7:40 AM on June 28
As an aside, “Medicare Advantage” is a scam name to entice Medicare recipients into a subsidized private insurance plan. Regular Medicare plus a “medigap” plan plus “part D” is pretty affordable and much easier to deal with in my experience. Though all insurers are headed to “the hot place” eventually. And no one telling you what physicians you have to see.
Perhaps at the next opportunity they might think about switching and it *might* be better. In any event, I wish them the best of luck.
Oh, and don’t discount the utility of calling their senator’s “constituent service” number. An enquiry from a legislator frequently has a salutary effect on these shitstains.
posted by Gilgamesh's Chauffeur at 5:10 PM on June 28
Perhaps at the next opportunity they might think about switching and it *might* be better. In any event, I wish them the best of luck.
Oh, and don’t discount the utility of calling their senator’s “constituent service” number. An enquiry from a legislator frequently has a salutary effect on these shitstains.
posted by Gilgamesh's Chauffeur at 5:10 PM on June 28
Since it seems Medicare is refusing to cover the meds in the dosages your friend needs and the topical formulation is not approved here and must be formulated off-label, is it possible to obtain it from a foreign source? Medications are sometimes available that are not approved here, and are often a fraction of the cost here.
That would bring its own set of difficult problems regarding the infusions, but perhaps the topical medication can be sourced from a foreign pharmacy? Is this something you've considered?
posted by citygirl at 6:01 PM on June 28
That would bring its own set of difficult problems regarding the infusions, but perhaps the topical medication can be sourced from a foreign pharmacy? Is this something you've considered?
posted by citygirl at 6:01 PM on June 28
Response by poster: If by Medigap plan, you mean a Supplemental plan, it is unfortunately not affordable for person. The cheapest Supplemental plan in person's area is as much again as the Medicare premium, which they can already barely afford.
I'm now thinking mentioning Medicare in the title muddied the water and it would have been better to post two Asks. The part of the question about getting the best Medicare plan/coverage for the person, -- I think we've gotten enough info on, or at least it seems there isn't additional info that would help further...
Given their needs and low income, expected future healthcare visits, etc., and everything we've been able to learn, it seems they will get the best coverage they can afford by dropping the Advantage plan and trying original Medicare. From what we are told, Medicare will cover the IV ketamine. So, we shall see.
— — — — — — — — — — — — — — — — — — — — — —
The outstanding question I would still love to get some info, or even just tips/suggestions/thoughts on is for sourcing topical ketamine; i.e.,:
— — — — — — — — — — — — — — — — — — — — — —
Who knows of legit sources of topical ketamine that would be significantly more affordable than the local compounding pharmacy's rate of $1,000+ for a month's supply? There is currently no insurance coverage available to person that will cover this expense (that we have been able to discover with countless hours of research, calls, chats, etc., ad nauseam).
Thank you for all the ideas and info so far! It has been helpful and is much appreciated!
posted by concinnity at 8:16 AM on July 1
I'm now thinking mentioning Medicare in the title muddied the water and it would have been better to post two Asks. The part of the question about getting the best Medicare plan/coverage for the person, -- I think we've gotten enough info on, or at least it seems there isn't additional info that would help further...
Given their needs and low income, expected future healthcare visits, etc., and everything we've been able to learn, it seems they will get the best coverage they can afford by dropping the Advantage plan and trying original Medicare. From what we are told, Medicare will cover the IV ketamine. So, we shall see.
— — — — — — — — — — — — — — — — — — — — — —
The outstanding question I would still love to get some info, or even just tips/suggestions/thoughts on is for sourcing topical ketamine; i.e.,:
— — — — — — — — — — — — — — — — — — — — — —
Who knows of legit sources of topical ketamine that would be significantly more affordable than the local compounding pharmacy's rate of $1,000+ for a month's supply? There is currently no insurance coverage available to person that will cover this expense (that we have been able to discover with countless hours of research, calls, chats, etc., ad nauseam).
Thank you for all the ideas and info so far! It has been helpful and is much appreciated!
posted by concinnity at 8:16 AM on July 1
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FWIW, those “If you can’t afford the medication, Astra-Zenica may be able help” type programs are not available to anyone on a government health plan (i.e. Medicare, Tri-Care, etc.)
posted by Thorzdad at 5:55 PM on June 27 [2 favorites]