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572651 tn?1530999357

Tips for Provigil/Nuvigil Approval???

A co-worker called this week with a question about our insurance - she was denied provigil/nuvigil, even though her doctor contacted the insurance company and appealed the decision.  She suffers great fatigue and the sample helped her a lot.  She was wondering if I had any clues as to how others get this drug approved since it is not an MS drug.

I suggested it needs to be done under the results  of a sleep study since it is a narcolepsy/sleep deprivation drug-am I making that up or did someone here have to do that to get this drug approved?

Any tips you might have, especially dealing with blue cross insurance is appreciated.

best, Lulu
29 Responses
Avatar universal
It's my understanding that Nuvigil is cheaper than Provigil. If that's true, try that tack first.

Also, there is some med whose name escapes me that must be mixed, but is basically Provigil. Someone, jog my memory, please.

Finally, these meds are antii-narcoleptics. Your friend might have to go through a few other of these to show they didn't work, etc., to finally to be allowed the real deal. Insurers make us go through these hoops but it might be worth it.

FWIW, Provigil didn't do diddley for me. I wish I could give mine to someone else.

572651 tn?1530999357
She said the samples they gave her made all the difference to her in keeping up with an active 9 year old son.  We'll figure it out somehow - we've never had a problem getting an rx if the doctor requested it.

BCBS just rejected an rx for me that my eye doctor wrote.  The chronic dry eye has also caused a constant red irritated eyes.  The drops she wrote, BEPREVE,  are not covered at all on my plan.  They want me to use some OTC drops, which she doesn't want me to do.  Eye doc says the OTC ones mess up the eyes permanently if you use them too much and she wishes they weren't allowed to be sold - much like nasal sprays, people get the permanent dilation with the eye drops. She substituted another eye drop - BCBS wasn't happy, but they did fill it.  
1396846 tn?1332459510
As you know I have the crappiest insurance known, but my neuro called my insurance and they approved it within a day. I am not sure what they had to say to get it approved but when I go back I will ask if I remember. I do know that my script is $865 for a month supply, so it is very expensive.

I don't understand insurance company's, if the doctors prescribe it, it is because the feel we need it and it should be covered. It is getting ridiculous.

848718 tn?1257138801
My insurance only allows Provigil with diagnoses of MS or narcolepsy, neither of which I have as a limbolander.

But a few months ago, I started on an off-label prescription of generic Adderall for my fatigue, and it's been a huge help. While it still isn't covered by my insurance since I don't have ADD/ADHD, I discovered that by buying it at Costco, it got the price for a month's supply down to $23 (after paying $60/month for several months at my regular pharmacy!), which is higher than my $10/month co-pay for generics, but well worth it.

Anyway, that class of drug doesn't work for everyone, but it might be worth the trial and error to find something that could work for her that's more affordable ...
572651 tn?1530999357
SM- I'll mention the adderall idea to her....   she has an official dx of MS.  

You're right, Paula - the insurance should cover anything the doctor says we need I'm afraid this is only the beginning ..........
Avatar universal
My insurance company is BCBS of Kentucky and they just denied approval of Nuvigal for me. I have taken samples and my fatigue completely went away. I had it because of an auto-immune condition called Ankylosing Spondylitis, AS. Without it I am completely unable to function. Does anyone no of a way to still get it approved?

704043 tn?1298056844
hi  i wonder if we all got something out to the ms society-  or association-and stressed how it helps, they could file the fda?? idk   but it helps me too, my ins wont pay, i too get samples when i can- so thats tough when you dont dfrive!!   theres got to be away-
429700 tn?1308007823
It was me with whom the doctor was going to order the sleep study; however, I haven't seen my neuro, yet.  I've talked to his nurse numerous times, and the sleep study thing dropped from the discussion.  Since most of the time we play phone tag, I don't know the reason why.  He ordered Ritalin and even sent his order through certified overnight mail, so I filled the prescription and started it the next day.  

I will see him Monday, so I will find out about the sleep study thing.  I do know that it is super expensive, so this could be why he held out before getting me to try the Ritalin.  I am even thinking about asking him about a prescription to fill through the Internet with a Canadian pharmacy in generic form.  By the lack of response via the nurse, I don't think he's too keen on that idea.  

The Ritalin isn't working as well as the Provigil, but I've just started it.  He'll likely want to increase the dosage.  Plus, I want to ask him about he long-acting version of it like Cosmobirdy is taking.  I wil say this, though.  It is way better than not taking any medicine at all for the fatigue.  So, if your friend cannot get approval perhaps this could be an option for her.  

I'll know more after Monday.  There's a lot going on with my health at this point, though.  We may spend most of our time discussing other health issues . . .

1453990 tn?1329231426
Methylphenidate and Methylphenidate SR are the generics and they are pretty cheap compared to Ritalin.  Dextroamphetamine Mixed Salts  are the generic version of Adderal.
I have used both.   I prefer the Dextroamphetamine Mixed Salts because the mixture of salts kicks in over time. A dose lasts me about 8 hours and it action is very predictable.   Methylphenidate lasts about 4 hours. Methylphenidate SR lasts about 8, but the drug has "steep skirts" and wears off suddenly (on me.)

I think the Dextroamphetamine Mixed Salts are one of the $10 for 90 days prescriptions  are your local *mart store.  The generics for these are very inexpensive.

Bob (with ADD who seems to know way too much about Schedule II controlled drugs!)
Avatar universal
I too was on Provigil for awhile and then my insurance company (when I had paid ins) stopped paying because I was only a "possible"......said it didn't fit the proper Dx for the drug......

Maybe we should start writing the drug companies and telling them the insurance companies are refusing to pay for their product after the docs write it.............My neuro said I had to have a Dx of hypersomnia or narcolepsy to qualify for it per my insurance co.......my neuro used to give me samples but after the insurance co refused to pay, he stopped?

Provigil made me feel like a whole new person!

Good luck and keep us posted
Please see my comment
704043 tn?1298056844
it is under clinical trials for ms- i think- lol im never sure about anything!! but the division of drug information in the fda center its under  drug evaluation and research- i think thats what it said-by the time its approved well...  its soo frustrating!!
bob these salts helps you!1 im going to check into it !  cainer
721523 tn?1331581802
I take concerta for fatigue. I have BCBS Anthem (Calefornia), but I live in MS.  Anyway, they gave me the run-around about Lunesta.  After one call from the nurse at my Dr.s office, they began to sing my tune.   I wish that I could have listend to that conversation!
Avatar universal
I have been fighting Blue Cross since January 2011.  I have MS and suffer severe fatigue.  I've been taking Provigil for about 4 1/2 years and it was covered by Blue Cross.  I was notified in Nov 2010 that BC would no longer cover this drug for an MS diagnosis.  My Neurologist appealed the Provigil denial 3 times and BC would still not cover it.  She then tried to prescribe Nuvigil again BC denied and she appealed that 3 times.  My Neuro decided to try the generic to Ritalin for the month of February.  I normally have a blood pressure of 120/80 by the end of February my blood pressure was at 165/98.  I could no longer take that.  Then we tried sleep studies.  I went for 2.  The first one showed that I had sleep apnea, so I went back for another and used a CPAP machine.  The apnea didn't improve that much with the machine so my Neuro submitted another authorization for Nuvigil for Sleep Apnea.  Blue Cross denied because my apnea fell below the number required.  Because I had been of the Provigil and Nuvigil for approximately 4 months I started noticing the changes.  I not only had severe fatigue, my body literally couldn't function.  I couldn't lift my arms and legs.  I had pain throughout my whole body.  I couldn't do grocery shopping.  I couldn't clean my house.  I've contacted our Senator, MS Society, BCBS of RI, Cephalon (drug company).  Nobody can help me.  The Senator was able to speak with someone at BC who wants me to do an external appeal.  I have to send in the denials with $144, and BC (CVS Caremark) needs to pay the other half.  They send it to a third party to review and if they determine that I need this drug BC has to approve it.  I was so desperate and scared that on April 19th I paid $173 for 14 Nuvigil pills (this is with a AAA discount).  To date I have paid approximately $1400 to get through the day.  Oh and one more thing.  I also have DOUBLE COVERAGE with BCBS of RI.  I refuse to go on disability because I'm not able to make throught the day.
Please see my comment. After calling a million pharmacies and researching, I found they have it at about $50 for 45 pills without insurance. I was spending so much like you were just to get through the days, $150 for 5 pills... Ridiculous. I got 135 pills from Costco for $130! If there's not a Costco near you ask your pharmacy to order from the cheapest manufacturer. They should do it for you, but will not like it probably.
429700 tn?1308007823
Your situation sounds like mine.  I have BCBS and was on Provigil for almost 4 years when I've been denied after several appeals.  I too have high blood pressure, but it is under good control even with the generic to Ritalin.  The trouble is, it's not working as good.  I was also thinking about retiring on disability, too.  I'm a teacher and I'm have severe cognitive issues (not to mention a few other problems).  The Provigil helped with the fatigue and cognitive issues.  

I'm through with the appeals to BCBS.  My doctor wrote me prescriptions for the generic of Provigil and I will be sending it off to an on-line Canadian pharmacy to fill.  It is actually affordable, so I'm going to try it.

572651 tn?1530999357
This whole conversation makes me sad/mad. We pay good money for our insurance and our doctors should be allowed to treat us as they see fit.  

Maybe BC will change their tune if enough people keep trying to get these drugs approved.

Avatar universal
Here is the disturbing part of all of us attempting to gain a portion of the quality of life that we had before MS.
The cost of research and development for Provigil must be considered before we start complaining about the price we pay for the drug. We also must take into consideration that the $1700 per month that my BCBSMA paid resulted in higher premiums for others who did not benefit from our expensive drugs when it had to be renegotiated by our employeers.
Provigil (Modafinil) was developed in FRANCE! In 1991 Cephalon bought exclusive rights to the drug in the US. The FDA allowed them to maintain control of the patent for 21 years. France also sold the Modafinil drug rights to many companies at the same time.
The FDA allowed Cephalon to charge $1700 for my 60 tablets per month, while the Canadian Government's version of the FDA allowed the company who manufactured the same formula (Alertec) for about $60 for the same 60 tablets per month.
I know that the US has very strict guidelines for manufacturing the drug and I am told the Canadian manufacturing process doesn't have strict guidelines so don't go there to get drugs!!!! I can only imagine that the people in Canada who are taking drugs and dying in droves must be quickly disposed of so we, accross the boarder, don't know. I also know what a terrible health care system they have... The World Health Organization rated them as having a better health care system than the US. How can that be? They must not be including all those who died from the drugs they were prescribed.
US Provigil (modafinil) = $1700 for 60 200 mg tabs, Canada Alertec (Modafinil) = $580 for 500 200 mg tabs.
Have you tried the Modafizone yet?  It is about $75 for 40 pills.  I have CFS and can only take a very small amount of the 200mgs, I can only take 1/8th of the 200mgs.  
Avatar universal
I don't have MS but I have had experience with real Provigil and fake Provigil  BCBS won't cover Provigil, even with dramatic results of a sleep study and literally my going to sleep at the wheel.Even with excessive caffeine I never woke up and most of my days were spent napping.  
The authentic Provigil samples from the Doctor and the Modafinil, manufactured in Canada, sold at Walmart in US (BUT THE PILLS ARE STAMPED PROVIGIL) are not the same.
Provigil, if I pay on my own, is $1,200 for 30ea 200 mg, while the Modafinil my Rx plan pays for is around $721.00.  This puts me at the upper limit of my coverage pretty quickly.  The samples gave me wonderful results when using only 1/4 tablet for four 4days per week.  The Modafinil I take 1/2 pill and get very limited results. I sometime take the other half later, but never a whole one at once. Leaves me jittery, something a whole Provigil never did (but then, after I found the price, I never took over 1/4.  I didn't realize how low I had gotten in my life until I was re-awakened with Provigil.It is hell - and totally unnecessary - to be handicapped and sick in any way and have real help in sight but out of reach.  If I ever win the lottery I know the first thing I purchase - I will go back to: my 1/4 tablet Provigil.
I understand a business's bottom line but what goes around - also comes around. God bless all of you just trying to have a good day for a change.
Avatar universal
I work in a retail pharmacy and am used to seeing the prior authorization responses from insurance companies. I also used to be on Provigil (brand) and now take the generic for it, Modafinil, and my insurance approves it, but I have had a sleep study with a narcolepsy diagnosis and my doctor's office has to get it approved every year for a one year period. It is not easy and the doctor has to be willing to fight to get the approval. The diagnosis does make a difference. Without my narcolepsy diagnosis I would be denied for this medication. I do the same with generic Adderall XR and generic Ritalin.
572651 tn?1530999357
Hi Linzr and cyberersal and medgreeddisgust -

thanks for adding to this conversation based on your own experiences.  Since Provigil went generic, I have been taking modafinil -  there are days I try to not take the pill and I find by about 3 pm or so, I really just want to put my head down on my desk and sleep.  This, of course, is not an option, so I go back to taking the modafinil and it does make a difference.

I hope that the situation with getting this approved will get better soon - so many of you would do better with the fatigue if you were able to take this pill.

Avatar universal
Hi.  I just lost my health insurance and waiting for COBRA, however I know Provigil or even generic Modafinil will be outrageously expensive.

Where do you buy Provigil or generic in Canada?  This happened to me once before.  I was spending around $800 or $1k on 1-30 supply of Provigil.  I was running up credit card bills.  My doctors did the best they could to get me free samples, etc.  Im at my last straw to finding a random site and ordering online and crossing my fingers my credit card does not get compromised.

Avatar universal
Unfortunately, you cannot get Provigil/Modafinil or Nuvigil from any reputable Canada pharmacy.  I am looking into any costs savings available now since my appeal for coverage was denied by my insurance company.  I will post again soon when I have more options to share.
572651 tn?1530999357
Hi, SherB852- you may not have noticed this is an older conversation and topgun asked that question last year.  Thanks for trying to help with this- getting some of these drugs for fatigue is incredibly frustrating.

The best recommendation I can make to everyone trying to get this type of drug is to have a sleep study done.  The insurance companyies will approve its use if there is a documented sleep problem.

If you can't get the provigil/nuvigil approved, since it is considered off label use for MS, you might talk with your physician about other drugs that might help, in particular the drugs prescribed for attention deficit disorder.

Avatar universal
I have had my doctor resubmit the prior authorization and request for the Nuvigil because her first submission was so not right.  No wonder it was denied.  I called my insurance company and asked exactly what did they need.  They said we could do a new request and they told me all the details.  I gave those to my doctor and told her they said to be very thorough.  I hope she does what I asked because I gave her all the info she needed.  I am waiting to see how it turns out.

In the meantime, I have found a nice discount with GoodRx.  They have Nuvigil coupons for both 150 mg and 250 mg.  Both coupons show about $536.  I even checked with my pharmacy and they said that is correct.  Tell your doctor what your plan is.  Even if you are taking 150 mg ask him/her to prescribe 250 mg.  This way you can cut your pills in half and they will last two months.  So here is where the savings is.  Rather than $536 for one month, it comes to $268 a month.  

Also, go to the Nuvigil.com website.  You can get a discount card for one month free of Nuvigil and refills will be $50 off retail.  That $50 doesn’t help a lot, but getting one month free is nice.  I did that.  I won't get the refills with that card but I plan to use Good Rx if I don't get approved for insurance coverage.
Avatar universal
I work for an insurance company and also had trouble getting it approved, largely b/c of how much the med costs the insurance company.  Because of the cost, the company has a medical policy for which conditions the med can be approved for based on best practices guidelines set forth by FDA and medical community.  Even for those conditions it cannot be first line treatment.  In appeal, MD had to outline that other first line meds were tried first without success. I have debilitating fatigue from Fibromyalgia.  In our medical policy, Provigil is not an approved treatment for Fibromyalgia BUT Depression is IF you've tried a certain number of meds without success = the criteria I fit.  I would recommend visiting the insurance company website and searching "provigil" in their medical policies. It could be, like in my situation, that she has a diagnosis other than what she is initially rx'd the med for that will qualify her for it, like depression which is very very common co-morbidity dx for those with chronic conditions.
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