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405614 tn?1329144114

Can insurance get any weirder?

I'm talking about coverage of medications.  I've mentioned before that my insurance won't cover Provigil because I don't have a diagnosis, though a trial of it helped me a great deal.

I called the company that makes it today, to inquire about their Patient Assistance Program.  If you have any insurance, you aren't eligible for their help, even if your insurance won't pay for their medication.  They will assist you in an appeal, but the guy I talked to admitted that it wasn't worth my time and effort, because without a proper diagnosis, it won't do any good.

I called in for one more refill today, and will ask my PCP next week about Ritalin or Adderall; my ms neuro suggested Ritalin if I couldn't afford Provigil.  I'm afraid that the Ritalin will give me tachycardia, as a similar medication did several years ago.  

Now I'm thinking; will my insurance even cover the Ritalin, without a diagnosis?  I should grab my formulary...  It lists Adderal as a tier 2 drug, with a higher co-pay; other amphetamine salt drugs (generics) are tier 1, and it doesn't list needing a prior authorization.  The side effects look a lot worse than those listed for Provigil.  I wonder how long the patent on Provigil lasts, and when there will be a generic form?

Does anyone else have trouble getting medications that they need or that are really helpful in improving your quality of life?

Ess and I discussed on another thread how both our insurances only allow you to get half a month's worth of Ambien.  Are we only supposed to sleep every other day?  I'm sure there are lots of other odd things about insurance and meds.

Back when I didn't have insurance, the drug companies Patient Assistance Programs shipped me all the meds I needed for free; I just had to fill out forms and have my PCP fill out a portion.  

Anybody else have issues with getting meds?

Kathy
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405614 tn?1329144114
I just picked up my refill of Provigil; $357.85 for 30 of the 200 mg. tablets.  In December I paid $306.  I'm on Social Security Disability, and that is just too much of my monthly income; I just can't do it any more.

The Provigil has really helped with my fatigue and improved my mental clarity.  I feel more safe to drive when I take it.  My neuro prescribed it, then my PCP did too, when she found out how much it helped me.  However, my PCP wrote my diagnosis as "cerebral white matter disease", which is not an approved diagnosis, so I have to pay cash.  My neuro hasn't given me a diagnosis at all.

The "FDA approved" uses for Provigil are Obstructive Sleep Apnea, Narcolepsy, and Shift-Worker sleep disorder.  Those are the only ones that my insurance will cover it for, and then only with prior authorization.

When I called the makers of Provigil, I was told they only did the Patient Assistance Program for people iwth FDA approved diagnoses, and since I have insurance, I'm not eligible even if i had a diagnosis.

Someone suggested I change insurance companies, but who knows which would be the right one,  especially until I get a diagnosis?

I'll just talk to my PCP next week about Ritalin.  Hopefully I'll only need to take it for a short while; either I'll get well (yeah, I can dream!), or I'll get a diagnosis that will help me with an appeal to get covereage for Provigil.

I'll enjoy my last 30 days of energy and clarity. Maybe I'll use the time to rejoin my water aerobics classes (carefully); I always felt so good when I was going to water aerobic regularly.

Hugs,

Kathy
Helpful - 0
620048 tn?1358018235
HI kathy,

Phendimetrazine is diet drug I wish you could get provigil, its a good drug and not a narcotic drug.  Its not an MS drug really, its for narcolepcy (cant spell it). I took it a tear before my diagnosis because of my fatigue.  I will use it as long as I can because all the other drugs are more addictive and you end up needing  more and more. I could get them if I wanted. But provigil is so worth the price I pay.

I give up shopping and work 2 days a week to pay for it right niw.  MY insurance pays 50% of it, still expensive but much better than $500.00.  Its gone up too since last year.

I dont understand why you cannot get it...it helps make you more alert also, unlike the others.

good luck, sweetie

hugs, meg
Helpful - 0
405614 tn?1329144114
Yep, more stories of insurance having odd formularies, strange rules they follow.

Maggie,  my insurance doesn't pay for weight loss aids; is that silly, or what?  If you need to lose weight (and I do), they would definitely improve your health and reduce your further health care costs!

I took Phentermine for a while, which helped control my appetite, and I had to pay cash.  I shopped around to find the lowest price, so it wasn't too bad; I wish it could keep me alert.  I looked up Phendimetrazine 105mg ER tablets in my formulary, and it's not even listed.  I'm going to my pharmacy today; I'll ask my pharmacist about the cost and side effects.  

It would be great if that could help with my fatigue as well as help me lose weight, and cost a lot less than Provigil.  Heck, I looked it up and it is also in the same class as amphetamines, and could raise my heart rate/BP.  I'll ask how it compares to Ritalin as far as side effects.  I think Ritalin reduces the appetite, too, and would cost me a small co-pay.

I'm so sorry about your lower back pain; I'm seeing my physical therapist about mine today.  I've had several MRIs, a discogram, X-rays, etc., and am told there is really nothing they can do.  No one has been able to tell me what to avoid to keep from making the pain worse.

Can't your PCP insist that you need a MRI?  Do you have to pay a percentage of the cost?  Ouch.  It is totally unfair to NOT see if there is something that can be done to reduce your pain and improve your quality of life.

Kathy
Helpful - 0
1 Comments
Hi Kathy,

Regarding your comment about something to help with fatigue & also aid in weight loss...try vyvanse. I started taking it for adhd symptoms & the drastic curbing of my appetite was an added bonus. I lost 15 pounds in 6 weeks, just by having the desire to eat less. I came to learn it is also prescribed for binge eating disorders, which I don't have, but was grateful for that side effect.

It is expensive, as is nuvigil & adderall 20mg extended release. I was spending $150-$900/mo on these. But my dr gave me a card that provided a 30 day trial for free. Then another card that allows for 30 day supplies at $15 for up to a year. After this point, it may cost as much as $75/mo, but I modified my insurance plan to allow for more prescription assurance when that 12 mo coupon runs out.

Hope this helps! Vyvanse has been great for me. I live in AK & the lack of daylight makes my fatigue unreal. Vyvanse gets me out of bed quickly & motivates me for a very productive day either at home with housework or while I'm at my job.

Best of luck to you as you work through your fatigue & the trial & error of meds that comes with that. I hope you feel better very soon.
Avatar universal
My PCP wouldn't even try to convince my insurance company I needed Provigil, he said it ws so outrageously expensive they would automatically deny me. He instead gave me a perscription for (generic name) Phendimetrazine 105mg extended release tablets. It does basically the same thing as Provigil, maybe not as strong. I was having trouble staying awake driving. I would feel like I was  awake, but really far away looking down at myself. Not good when you drive for a living, LOL. I have had no trouble since starting this.  It's main use is for weight loss. Therefore necessitating a visit for new perscrip every month.  My insurance pays for it with no questions.......this from a company who will not authorize a MRI on my lumbar spine. My old one is over a year old, and am having great deal of pain walking. Said I hadn't tried conservative measures, such as PT, anti-inflammatories, etc.  My PCP didn't want me doing PT until we found out if bulging disc was worse. I ended up doing 24 sessions, with no change in sx. Now can't afford the MRI, so just live in pain. Insurance companys just take our money, they don't give a da*m about us.  Take care, and stay dry.

Maggie
Helpful - 0
152264 tn?1280354657
Must be a difference in insurance companies. Mine paid for Provigil, Ritalin, you name it--all without any diagnosis.

It's crazy, though--my insurance pays hundreds of dollars a month for my Strattera--two 40-mg pills. But when the manufacturer finally came out with an 80-mg pill (cheaper, because Strattera is priced by the pill) and I tried to save my insurer money by taking 80 mg once a day instead of 40 mg twice a day, they refused to cover the 80 mg pill (because it was "too new").

It makes no difference to me because I only have a small, set co-pay per Rx, but my crazy insurance company would rather spend $1200 a year more on my medication than it needs to. OK, whatever--I TRIED to do a good deed!

The stories here are just unbelievable.

Nancy T.
Helpful - 0
405614 tn?1329144114
Wow, I wonder if the insurance company would have paid to keep you in the hospital and on the blood thinners if you couldn't pay for them.  It seems like it would have endangered your life to send you home without them, and they would be liable.  I'm glad they reimbursed you!

I have a friend that contracted MRSA (drug resistant staff infection) in her lungs when she was in the hospital with pneumonia.  She was on IV antibiotics for quite a while, then they wanted to send her to a nursing home rather than send her home with a  prescription of EXTREMELY expensive oral antibiotics.

She had a discussion with the hospital about them GIVING her the staff infection (long story, but true), and before long, she went home with her oral antibiotics.  I think the hospital paid for them, not the insurance, but I'm not sure.  It just seems bizarre that insurance would pay for a couple weeks of around the clock care at a nursing home rather than give someone an expensive Rx.  BTW, she lives two blocks from the hospital.

Helpful - 0
279234 tn?1363105249
I've had issues with our insurance company. This is a repeat from what I put on my thread :

I'm currently fighting with mine over a shot of birth control I got to control an ovarian cyst. My doctors and I decided we would use the Deprovera shot...It was either that or lose the only ovary I had left. My insurance company doesn't want to pay for the shot...They said they would have covered it if it was the birth control pill but this wasn't an option for me because of the blood clots I got in my leg last year. Deprovera was my safest option. So I have to send them medical records and a letter from my doctor, that I'm still waiting for on proving my case, before they will consider it.

The thing is my is I saved my insurance money....pay for a $75.00 shot or a ovary removal surgery which would have been in the thounsands and they are putting a fight over what birth control method that was the safest for me to use. It's common sense, that I couldn't use the pill if you've had blood clots...and they are telling me that since I chose a method (the only method that was considered safe) they aren't going to cover because the shot isn't covered. It's not like I needed it for birth control..I have no uterus.

I also had to pay for my Lovenox shots (blood thinners) when I got out of the hospital. They were $650 for 10 shots. My insurance company did reimburse me and I had to wait on a check from them, but I kept thinking, what if we didn't have that money in the bank to begin with...what then. This was something I needed and I had to have.
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