Aa
Aa
A
A
A
Close
405614 tn?1329144114

Denial of Medicare RX drug coverage; Provigil

I received a letter of denial for Provigil coverage after a free week's trial (from the drug company).  The Provigil made a world of difference, but is really expensive.  My other option is Ritalin, and I don't like the sound of the side effects.  I had no negative ones from Provigil.

My PCP's office called to see if I'd started the appeal process, and I told them that I thought it would be best coming from them, since they new how to word things, having dealt with insurance companies for years.  My  PCP isn't in today, and she apparently has the letter of denial that  I faxed to her, so her medical assistant wasn't sure if they could help, so she suggested I start the appeal on my own

Has anyone tried this?  Is it worth the effort?

I don't have a diagnosis, except fatigue; nothing to back it up.  Who knows when or if I'll get a diagnosis of MS or some other neurological disorder.  They are very specific; only cover provigil for "obstructive sleep apnea, narcolepsy, shift work sleep disorder, and only when other treatments for these conditions are not an option".

Maybe I'll fax a letter to my PCP requesting her help with an appeal, quoting specific requirements from the appeals process.

Has anyone tried this themselves?

Kathy
15 Responses
Sort by: Helpful Oldest Newest
405614 tn?1329144114
Hi there!

I'm starting to get more energy back after my virus and trip to Disneyland, so I'm feeling prepared to keep fighting.  I've been planning a letter to my PCP in my head; just need to put it on paper and get it to her.

Well, I don't have the diagnosis of  MS or Parkinsons or the 3 others on the list that I know of, so who knows if I'll succeed, but I need to try.

I don't want to have any more tachycardia or irregular heartbeats.  My MS specialist has been trying to say that I have had mini strokes from past arrythmias, and that all my symptoms are from them.  Both my cardiologist and PCP would  disagree; my PCP told me to my face that it could not have happened from the mild arrythmias that I've had.  

I don't want to have to deal with any more arrythmias that might make Dr. Y. think that she is right.  I wrote her a note requesting a CT angiogram to look further into the possibility of small vessel ischemic events, as she is so sure.  She hasn't replied.

DJ, it is great to see you; thanks for the hugs and love and encouraging words.

Lori,  thanks for the information and your experiences with Provigil Rxs.  I'll make sure that my PCP is more thorough in her information that she sends to the insurance.  They didn't have the info about my 150 resting heartrate while taking Cylert; I'll see if she can come up with some more supporting evidence of medical necessity.  She's done it for my Prevacid and Mircette; Provigil is WAY more expensive.  Things will work out.

Kathy
Helpful - 0
Avatar universal
To obtain Provigil you have to have specific diagnoses. Medicare has a list of seven items that have to be checked off in the doctors progress notes to receive approval for anything. This medication is indicated for MS & Parkinson's disease.

When I took Provigil, I would get to the pharmacy with a newly written prescription...the Pharmacist would say," the insurance company needs more information from the doctor".  So I would have to wait a few days until the insurance company verified with my doctor my dx.  This didn't happen when the doctor called in refills.

You are going to have to keep calling Medicare and the doctors office to contact Medicare concerning the medication. Most Medicare denials are due to a lack of information in the Dr's progress notes.

I take Adderal which is just like Ritalin and I prefer it better because it doesn't make my heart race or cause me to breath hard, so it's not a bad option if you don't want to fight Medicare.

Lori
Helpful - 0
611606 tn?1315517767
Hi Lady, I have no info to help you, but wanted you to know you mustn't give up. I had a similar problem with one of my drugs and medicare, Both my Dr. and my Druggist wrote Medicare and some how they won an approval for me. I can't remember right off hand which drug it was because it was a few years ago.
Just keep fighting for what you need. I hope you will win!!!
Sending you hugs & Love...DJ{{{{~!~}}}}
Helpful - 0
405614 tn?1329144114
It was Cylert that I took around 1985 that gave me a resting heart rate of 150.  I thought that since it was a similar drug, I would have similar issues.  I recently looked up Cylert, and they've pulled it from the market for damaging the liver or something like that.

I would prefer not to try those drugs, but if necessary as a test before getting approved for Provigil, perhaps Adderall would be the better choice, at a small dose.  Dr. Y. suggested 5 mg. of Ritalin to start with, so 5 mg. or Adderall would be OK, and if it triggered my arrythmias, maybe that would be evidence that such drugs are not for me.

If it works without bad side effects, I could use some clarity and more energy for my cooking and baking; I haven't used my bread machine in ages, and many of my cookbooks are getting lonely!  :o)  

I think Provigil would work just fine, though.  I did a lot more that before with its help.

Jo, I didn't think of a patient assistant program; I used to get most of my meds through them before I got prescription coverage.  Thank you!

I know that some companies help even when you have insurance, if they consider you underinsured.  It's definitely worth looking into!  

Kathy
Helpful - 0
147426 tn?1317265632
With your "mild" history of arrhythmias, the stimulants Ritalin and Adderall may cause problems.  But, at a low dose they may not.

Jo (Hi, there!) found pretty much what I found when I treated ADD in practice.  Many more kids felt much better on Adderall than on Ritalin.  They all said it made them feel okay or less weird.  They are both central nervous system stimulants.  Ritalin is less stimulating that straight amphetamines.  Adderall is a "mixed salt" of amphetamines.  Both have potent potential for triggering arrythmias.

Q
Helpful - 0
333021 tn?1207759633
Hi Kathy

I had the same problem with my insurance paying for the Provigil..  It would have cost me over $300 a month. $10 a pill , I bought three to see what they were like. I only took a half of one and felt strange, so I knew it wasn't for me.

  The next thing I tried was Ritalin . That made me very tense and sort of angry  and some tachycardia..   now I'm on Adderall RX and its just right   :).  I started out with 5mg because of my rapid heart rate worries .  That went well and now I'm taking 10mg and my pulse is a steady 80 bpm , no anxiety or jitteriness , its gentle .  Oh , the best part is I want to do things.  Shower , huge!!  :)    Dishes , cooking , I can walk faster, laundry is getting done .... (after being on 10mg awhile I'll up the dosage a little more and see how that goes...)           I still have the cog fog .. but hey..  

My neuro said something about the MS cog fog being in the ADD category ..and  they , in the medical community are just coming around to this understanding .  So these drugs are important to us ..  to help us with energy yes , but also to help focus . there was more but I can't remember..:)    ..  I really need to explore this .  

I found a couple of sights that will help with getting drugs that the  insurance plans don't pay for or if you're uninsured:    needymeds *******    
                                              RX Outreach Patient Assistance Program
  Try Google ing the second one, see if it will come up in the search , if not I'll try to post it properly.

Jo





Helpful - 0
405614 tn?1329144114
I thought that all Medicare Drug Plans had the same rigid rules for what drugs they allow; my friend with an insurance license said that most insurance companies go by Medicare guidelines so they don't have to cover expensive stuff.

My plan is included with some pretty good coverage, but I'm willing to look at other plans.  If you could PM which plan you use, I could check into that.  It seems that there are always informational meetings about various plans during open enrollment, too.  I wonder if the speakers answer specific questions, like do you cover Provigil?

The diagnosis thing is probably the catch.  At least my PCP tried, with her idea of what my diagnosis is.  I do need to ask her for more info about this "cerebral white mattter disease" that she says is a specific disease, not a catch-all phrase for all white matter diseases.  

I have a great relationship with my PCP; have had for a decade, so I'd like to stay with her.

Would Ritalin be a bad thing for me to try? Does it not work as well, and will it increase my little runs of tachycardia?  It doesn't sound good to me.

GrannyJo, yes, its frustrating!  My PCP didn't want to prescribe it a few years ago when my pain specialist wanted me to try it, but now, with all the neurological symptoms, and my MS specialist writing the rx for the free week's trial and it helping, she's all for it.  She has watched me be fatigued for months.

We'll fight for this together; if all else fails I'll buy what I can afford each month, and use them sparingly.  They helped that much.  I'm pretty good at being persistant.

Does anyone know of any studies that show Provigil is good for fatigue caused by other that the approved list for Medicare?

Kathy
Helpful - 0
147426 tn?1317265632
This month is open enrollment for Medicare Drug Plan changes.  Why don't you investigate a plan that pays for Provigil?  Mine does.  Mine has a pretty broad range of doctors also and is based in Portland.  what I don't know is if they will approve it without a diagnosis.

You can change around the drug plan every year and it does not have to be the same plan that you use for medical services.

Quix
Helpful - 0
627818 tn?1271777026
How frustrating for you! Isn't it crazy that you can't get the meds that really help you and that your own doctor deems necessary but the insurance company who doesn't know your medical history from Adam's thinks they know what is best! Grrrrrrrr! Hang in there - sounds like it is worth fighting for!
Helpful - 0
405614 tn?1329144114
HUGS BACK AT YOU!  I'M TOO TIRED TO SAY ANYTHING INTELLIGENT, BUT THANK YOU FOR YOUR KIND AND SUPPORTIVE WORDS.  

I'LL GET AHOLD OF MY PCP ON MONDAY AND ENCOURAGE HER TO KICK SOME BOOTY AT THE INSURANCE COMPANY!

NIGHTY NIGHT

KATHY
Helpful - 0
Avatar universal
Hi Kathy,

Sorry you're having to deal with this, it's always something isn't it?  I agree that you should let the dr help you with this appeal.  You're right, they know what they need to say and how to say it.

I hope that you get this resolved soon so that you can take the Provogil.  Any help to reduce fatigue is a wonderful thing.

Have a good weekend.

Hugs
doni
Helpful - 0
Avatar universal
KATHY,

ITS BEST YOUR PCP BATTLES THE INSURANCE COMPANY,GOOD OLD MEDICARE,THEY PREFER RITALIN OR A SIMILIAR MED FIRST.

FATIGUE ALONE SHOULD OF BEEN ENOUGH,IF IT'S A GOOD PCP HE WILL GET YOU THE PROVIGIL.

MY PCP HAD TO CALL AND EXPLAIN THAT I COULDN'T TAKE THE RITALIN AND THAT I NEEDED THE PROVIGIL.

IT'S POLITICAL MUMBO-JUMBO ,BUT THEY PREFER A CHEAPER,GENERIC MED FIRST BEFORE A HIGH PRICED ONE.

HANG IN THERE,PAST  RECORDS SHOULDN'T BE NECCESARY,CONSTANT FATIGUE SHOULD OF BEEN ENOUGH. DARN INSURANCE COMPANIES.

I WOULD ASK ABOUT THE EXPLANATION SENT TO THE INSURANCE CO,FATIGUE FROM CEREBRAL WHITE MATTER DISEASE.GEEZ THAT SHOULD OF BEEN ENOUGH INFO FOR THE INSURANCE COMPANY.BUT THEY WANT A CLINICAL DX.
HECK THE PCP COULD OF PUT DOWN CHRONIC FATIGUE SYNDROME.

KEEP TAKING YOUR DEEP BREATHS,PROVIGIL KEEPS ME GOING BUT I STILL NEED MY NAP.

HUGS

T-LYNN
Helpful - 0
405614 tn?1329144114
I called, actually talked to BCBS pharmacy specialist; he said that my diagnosis was "fatigue from cerebral white matter disease", which is a diagnosis without medical proof that Provigil is helpful for.

DUH!  I'm sorry, but I wish I had an actual diagnosis!  I know that some people get Provigil covered.  I'm going to ask my PCP for more information on this "Cerebral white matter disease" that she's sure I have.  She says it has only been recently seen in younger people; was normally seen in people of much more advanced age.

I was told to ask her to send more information on why this medication is medically necessary for me.  When I told the pharmacy guy that a drug similar to Ritalin gave me a resting heart rate of 150, he about choked.  He said that is definitely the kind of information that makes a difference.

I'll have to suggest that my PCP get my records from the ambulance company (AMR) that came and checked me out and insisted on taking me to Providence when my heart rate was so high, just sitting still.  Do ambulance company's keep such records for 12 years or so?  I couldn't pay them, so they kept sending me collection notices for a long time; they must have had a big file on me.  They finally realized they couldn't get blood out of a turnip.  I had told them up front that I didn't have insurance, couldn't afford to pay, but they said that they had to take me in with a heart rate that high.  Arghhh!

Providence's records most likely won't show the high heart rate; I was low priority and was released after two hours with the diagnosis of "chest wall pain".

Deep breath, I'm calm now.  Things will work out, they always do.

Kathy

Helpful - 0
405614 tn?1329144114
Thanks, great advice!  I've ran across some real stinkeroo customer service reps, but I've found others that would just about come over and help me with the paperwork (not really, just showing the contrast :o) )

Oh, heck, I looked at the paperwork, and the appeals go through Medicare, though I pay a bundle for a BCBS MedAdvantage policy; I think Medicare is the toughest of all.  Oh well, they still might have a good customer service representative!

Kathy
Helpful - 0
572651 tn?1530999357
Kathy,
i would definitely go through the doctor for the appeal - the insurance company is very likely to dismiss your request without giving it full consideration.  You could call them and talk to someone about the appeal process and get their inside opinion.  I find the customer service reps for my insurance company are usually very personable and helpful (but sometimes I get one that is stinky!).  Feel them out and ask if that is something you should do on your own or if it must be done by the doctor.  then go back to your PCP and have her do it.

my best, Lulu
Helpful - 0
Have an Answer?

You are reading content posted in the Multiple Sclerosis Community

Top Neurology Answerers
987762 tn?1671273328
Australia
5265383 tn?1669040108
ON
1756321 tn?1547095325
Queensland, Australia
1780921 tn?1499301793
Queen Creek, AZ
Learn About Top Answerers
Didn't find the answer you were looking for?
Ask a question
Popular Resources
Find out how beta-blocker eye drops show promising results for acute migraine relief.
In this special Missouri Medicine report, doctors examine advances in diagnosis and treatment of this devastating and costly neurodegenerative disease.
Here are 12 simple – and fun! – ways to boost your brainpower.
Discover some of the causes of dizziness and how to treat it.
Discover the common causes of headaches and how to treat headache pain.
Two of the largest studies on Alzheimer’s have yielded new clues about the disease