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Ihelp: Insurance Approves Just Half My Nuvigil Dosage

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#1 raouf

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Posted 24 January 2013 - 01:38 PM

Hi All,

 

I have lived N for the past 8 years. I started with Provigil and moved to Nuvigil 12 months ago.  My dosage has been 500mg Nuvigil (2 tabs of 250mg) a day.  The 500mg dosage of Nuvigil combined with 20mg of Celexa ( for cataplexy) and a healthy lifestyle  allows me to live a "normal" life. I just switched to AETNA insurance with my new employer and Aetna DENIED the prescribed dosage to only approve250mg a day.   My doctor appealed and was turned down.   I am writting an appeal to Aetna, but I have very little faith of a positive outcome.

 

IF denied, I will go to the courts in the hope that the courts will oblige Aetna to accept the dosage.   Has Anyone ran into a similar experience that can provide me with some advice?

Are there standard appeal letters I can use to file my appeal?  What supporting document should I include?

 

I consider Aetna's behavior to be CRIMINAL.  Aetna knows that I can get into an accidentat any time  and seriously hurt myself and others, but they still deny me the meds.    There is something wrong with our Healthcare system and Justice system where minors are sent to jail for stealing snicker bars and insurance companies are free to commit 2nd degree murders.

 

I welcome your input and advice to get through this situation.

 

Thank you,
foufou

 

 

 



#2 Rrrapture

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Posted 06 January 2014 - 08:06 PM

I'm having problems with insurance covering the amount of my night medication (Sonata) that I'm prescribed. It's pretty frustrating. The doctor's request for prior authorization has just been denied. Now I'm in the process of figuring out if the doctor should fill out the form differently, or what. Insurance is Anthem Blue Cross PPO. (California).

 

What's the status of your case?



#3 raouf

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Posted 02 April 2014 - 12:49 PM

Hi, 

 

Sorry for the long hiatus.  I had my doctor appeal it a couple more time in vain. I tried to take them to court but I was doing lots of travel and had too much on my place.  At this point,  I am paying Out of Pocket for the extra 30 tabs, which is what Aetna and all these pharma companies want right? for us to pay $24/per pill.   I also tried buying from India. I received the meds but I think they're sugar pills at best.    I am still searching for a legitimate foreign supplier...more on that. 

 

I am having my doctor go through the process all over again as I am tired of paying so much.    Other than that, life if good :)

 

How about you?

 

Ciao



#4 Lousyskater

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Posted 11 April 2014 - 12:39 AM

Makes me happy my company got rid of Aetna last year.



#5 chichi

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Posted 18 April 2014 - 01:23 PM

I have Aetna and am on 500 mg nivigil. It is covered. Granted it takes a letter from my dr each year to recerrify it's the only one that will help me. It literally takes just one phone call and it gets approved. I wonder what is with the Aetna you have.

I was paying 800+ a month but now it's 350 for 3 months worth.

I really hope it works out for you

#6 chichi

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Posted 18 April 2014 - 01:24 PM

Forgot to add that Aetna is my health insurance however it's Medco/Express scripts that handles the scripts. That is probably the big difference

#7 Hank

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Posted 18 April 2014 - 01:29 PM

What is and is not covered has less to do with Aetna and more to do with the specific coverage which your employer has negotiated.

#8 chichi

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Posted 18 April 2014 - 02:55 PM

True bit it's absolutely nuts how different it can be.

#9 raouf

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Posted 21 April 2014 - 09:13 PM

Thank you all for the feedback.  I have an Aetna PPO insurance through my job with Dental, vision..etc.  I picked this plan as it was the most expensive with the highest coverage( or so I thought).  My ID starts with a W 2006, Choice POS2.   My employer is the Children's National Medical Center. 

 

So, according to my Doctor last email  ".. I had several calls with your insurance and did the appeal and they denied it. However, I made another appeal citing your safety to maintain vigilance during the day and waiting for them to answer. I had to leave this time a voice message for this kind of appeal and the message says that they will call me only if they approve it while if not they will not call." 

 

It's been over 10 days and I haven't heard back from my doctor. At this point, I assume that his appeal was denied again. 

 

I surprised to hear that most of you had no real issues getting approved, is my doctor doing something wrong?  Any advice on how to proceed? I am almost tempted to ask my doctor to prescribe me Provigil to replace the 2nd Nuvigil pill. 

 

Thank you all



#10 raouf

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Posted 21 April 2014 - 09:16 PM

Rrrapture

 

Did you get the approval for your meds?



#11 raouf

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Posted 21 April 2014 - 09:20 PM

@ Chichi, 

You're paying $350/month out-of-pocket?



#12 Hank

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Posted 22 April 2014 - 04:47 PM

Ask your doctor to call the medical director of the plan. They can speak to each other- it is done.

#13 raouf

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Posted 23 April 2014 - 12:34 AM

Hi Hank, 

 

here is the email I received from my doctor:  

 

"Just to let you know that I had several calls with your insurance and did the appeal and they denied it. However, I made another appeal citing your safety to maintain vigilance during the day and waiting for them to answer. I had to leave this time a voice message for this kind of appeal and the message says that they will call me only if they approve it while if not they will not call. I will keep you posted. "

 

I am not sure what he's doing wrong, but i'd really appreciate it if you had any specific steps for the doctor to take (phone numbers to call..). 

 

Thank you, 

R



#14 Hank

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Posted 23 April 2014 - 05:44 AM

He probably spoke with a claim representative at the insurance co. The medical director is an MD.



#15 raouf

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Posted 23 April 2014 - 11:36 AM

Where can I find the number for the medical director? Aetna member representatives are giving me the run around.... :(



#16 raouf

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Posted 23 April 2014 - 11:55 AM

I have spent the last 1.5 hrs talking to various Aetna member services and none of them are sticking to the same script "call member services". 

 

Can someone provide me a phone/fax number of the medical director  for my doctor to call and approve my new Nuvigil dosage?

 

thank you



#17 Hank

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Posted 23 April 2014 - 12:16 PM

It doesnt work that way. Your doctor has a special number for provider relations. Your doctor needs to initiate this if he is willing- not you. If he is not willing, and not all doctors are, then finding a phone number doesnt matter anyway.

This is not a process that Aetna will help you with. If you get yourself involved, you will defeat the process. And dont go off half cocked and tell your doctor this is what he has to do, you need to ask if he would be willing to advocate on your behalf. Be smart about this.

#18 raouf

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Posted 23 April 2014 - 12:47 PM

Hank, 

You misunderstood me. I didn't initiate this dosage increase, my doctor did.  Since my doc was denied the same request last year, this time I wanted to help pass along any information he might have missed the first time.   I am also feeling more tired than my usual and having more attacks (perhaps caused by stress)

 

I don't understand how insurances can deny a claim when a doctor's argument is about a patient's physical safety .  

 

The doctor initial request on 4/9 was denied. He appealed on 4/21 and it's in pending review status. 

 

thanks



#19 Hank

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Posted 23 April 2014 - 02:27 PM

I was not discussing your dose, only your insursnce question- that is what your question was about.

What I am saying is this
1. Your doctor has a provider relations phone number
2. Your doctor can use thst number to try to speak with the medical director for your plan
3. Your doctor has to initiate this call and must be willing to do so
4. The above is not a process in which you can participate and you need to stay out of it

Does that make sense

#20 purpley

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Posted 23 April 2014 - 06:07 PM

Actually, Hank's right that you can't help by contacting people directly, but there is a way you can help your doctor do this, if you have the resources or knowledge, or someone can help you: by writing a letter which cites articles or other data that supports the use of higher doses, and gives your history of other medications which you've tried and haven't worked. I know people who've done this, written the text of appeals letters themselves and given them to their doctors to use, and it's often very successful. Doctors just don't have the time to do that research. Sometimes you can find other people who've already written such letters and are willing to share them. Or you can pay a medical student or graduate student for a few hours to do it, since they have access to all the medical databases -- it's a bargain compared to what you pay out-of-pocket for some of these meds.

Also, drug company reps can be valuable free sources of this kind of information for any brand name medication. They are more than happy to help you prove that you need what they sell. The only problem is that they can't help if you're trying to get a dose approved that's above the maximum dose approved by the FDA, or if it's for an off-label use. So PWN are usually out of luck.





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