I certainly hope my answer can help you with your situation. Since the questions you submitted are lengthy, we are going to break them up in sections.


Issue 1: Insurance is not paying for fentanyl any longer.

This is an extremely common occurrence and the process is rather simple when all parties understand what is being asked for and what needs to be done. The main point is that the dose your mother is being prescribed is outside of the formulary limits for the insurance company. The usual dosage for fentanyl patches is one patch every 3 days (although there are reasons for it to be dosed more often as I will discuss below). When a dose falls outside that range, it will generally not be covered without a 'prior authorization'.


Again, prior authorizations are very common and any retail pharmacist likely sees many of them on a daily basis. In a nutshell, a prior authorization occurs when your insurance company denies initial payment for a drug for whatever reason (e.g. unusual dose, safety concerns, expensive brand name drug etc...). When a prior authorization occurs, you doctor must supply valid reasoning of medical necessity for the prescription, directly to the insurance company. In other words, the doctor needs to explain why your mother needs fentanyl dosed outside the usual dosage guidelines.


It is important to note that the insurance company isn't telling your doctor they can't prescribe the medication as is...they are saying they won't pay for it without a prior authorization. In your mothers situation, the doctor could discuss prior therapy your mother has been on, stating that one patch every 3 days provided inadequate pain control. I don't know if your mother is taking medication for breakthrough pain, but often times if a patient needs to take 3-4 doses of breakthrough medication, that could be indicative that the chronic pain control needs to be adjusted, such as changing fentanyl dosing from one patch every three days to one patch every two days.


Your mother's doctor stating 'no prior authorization needed' does not solve the issue and will result in the prior authorization being denied. They MUST submit paperwork supplying justification. 


Our recommendation is to do the following:

  • Contact the insurance company to understand the reason for the prior authorization requirement. They most likely will say it is a 'high dose' and outside of the 'usual prescribing guidelines'. If you can't get a clear answer from the insurance company, your pharmacy may be able to help in this regard. When a pharmacy transmits a claim via their computer, they typically will receive a reason from the insurance company in regard to why the claim was denied. 
  • Contact your mother's doctor and make them aware specifically why the prescription was denied. Once they know the reason, they can supply medical justification as to why your mother is being prescribed the drug as it is. Furthermore, the insurance company should be able to provide the appropriate form that needs to be filled out.


To conclude this question, please know that these situations are very common but can be confusing and difficult to navigate. It appears to me to be as simple as the dose prescribed being too high per the insurance company. If the dose falls outside of their formulary range, it will require a prior authorization. Prior authorizations follow a well defined process (e.g. filling out the appropriate paper work). Please look at the Wikipedia article on 'Prior Authorizations' as it describes the process well.


Issue 2: Pain control is not lasting the full 3 days

This is a well known issue with fentanyl. In fact, the brand name product (Duragesic) specifically lists this in the prescribing information:

"A small proportion of adult patients may not achieve adequate analgesia using a 72-hour dosing interval and may require systems to be applied at 48 hours rather than at 72 hours, only if adequate pain control cannot be achieved using a 72-hour regimen."


In addition, many medical journals discuss this issue and give possible explanations for it. One article states the following:

"... In many patients, the analgesic effect lasts for 72 hours; however, some patients may find that the effect begins to decline after 48 hours, usually at around 60 hours. Fentanyl is delivered to the systemic circulation from the transdermal patch by diffusion from a higher to a lower concentration gradient. As the two concentrations become closer, the system becomes less efficient and less fentanyl is delivered, especially during the last 48 to 72 hours after patch application."


So, analgesia not lasting 72 hours is well known. Often times doctors, will use certain indicators as evidence that pain control is not sufficient. For example, if a patient is using a breakthrough pain medication (e.g. immediate release opioid drug) more than 3 times daily, that is evidence a patient may need a stronger dose of the chronic, around the clock pain medication. A common change for fentanyl is to alter dosing from every 72 hours to every 48 hours.


Issue 3: Does heat affect how fentanyl works?

There is evidence that strenuous exercise can affect how fentanyl is released as overall body temperature is changed. If something is altering the skin temperature, theoretically this could be causing problems. It is well known too that external heat sources will greatly accelerate drug delivery. External heat sources such as heating pads, saunas, and hot tubs have shown to increase fentanyl release by over 100%.



Issue 4: The pharmacy will not fill the fentanyl prescription/accept coupons

In regard to the actual filling of the prescription.... Whether or not an insurance company will pay for a prescription has no bearing on if it can legally be filled at a pharmacy. If that is the reason the pharmacist is giving, that seems incorrect unless there is more to the situation that I am aware of. I'm glad to hear the pharmacist checked with the doctor and decided to fill the prescription, determining it was valid.

Lastly, pharmacies cannot be required to accept coupons for controlled substances due to concerns with drug diversion. I checked the GoodRx website and they state this as well.

I certainly wish you luck and please contact us again if needed.