Jump to content


Photo

Getting Insurance For The First Time-Need Advice


  • Please log in to reply
6 replies to this topic

#1 CarlaWilS

CarlaWilS

    Member

  • Members
  • 30 posts
  • Gender:Female
  • Location:Indianapolis
  • Interests:Food! Music, singing, writing, movies, reading, baking, chocolate, cookies, flaky pastries, bread. Just food. Lots of food. Mainly sweets.

Posted 03 June 2013 - 08:51 AM

In the next few months, I'm planning on moving from Indiana to NYC. Currently, I am on my mother's private insurance plan as a dependent (I'm 24). I was diagnosed with N last March and since then, I've had so much trouble getting insurance to cover my medicine. I posted about my specific problem in another post, but to make a long story short, my policy is with Anthem Blue Cross Blue Shield and they are denying coverage based on a benefit exclusion in my contract that states that they won't cover any treatment for mental health. Apparently, every stimulant is categorized as a mental health medicine (sort of off topic, but does anyone know if this is what the drug manufacturers categorize it as, or is that something the individual insurance companies get to decide?).

 

Not surprisingly, I'm looking to find some new insurance. It's terribly difficult figuring out what medicine will work for me if I have to pay up to $800 a month just to try something. At the moment, I'm on 25mg Adderall XR and it's the first medicine I've tried that actually works. But it wasn't covered and I spent $163 for it. I'm just out of school and have a very limited monthly budget. Once I move to NYC it will be even more limited.

 

Does anyone have advice on finding a good insurance plan that will help cover my prescriptions and allow me to see a neurologist? I don't have any other health issues other than asthma, but I just need to be able to get an inhaler prescription, so I don't need to see a special doctor for that. If anyone has advice about policies in NYC specifically, or recommendations on sleep doctors or neurologists in the city, that would be extremely helpful, too. Thanks!



#2 Hank

Hank

    Member

  • Members
  • 1,327 posts
  • Gender:Male

Posted 03 June 2013 - 09:25 AM

I have Blue Cross and have never had a problem. The Group that you are part of may have specific restrictions.

Narcolepsy is not a mental health diagnosis- it is a medical diagnosis.

You should appeal the denial. Speak with your prescribing physician's office. They will be familiar with the appeal process and prior authorizations.

Here is what is probably happening. In order to contain costs, "Your Group" has elected to "not cover" certain medications commonly used for mental health diagnoses- like ADHD, for example. However, "My Group" has not chosen to have that restriction and Adderall is "covered" under my Anthem BC plan. Therefore, it is not an Anthem issue, it is a Group issue.

Because Adderall is most frequently used for ADHD, it is considered by your "group" as not covered.

When you fill your prescription at the pharmacy, the diagnosis is not a consideration.

So, appeal this denial and you should be able to have it approved. You will just need the support of your physician that your Adderall is for a medical condition.

#3 CarlaWilS

CarlaWilS

    Member

  • Members
  • 30 posts
  • Gender:Female
  • Location:Indianapolis
  • Interests:Food! Music, singing, writing, movies, reading, baking, chocolate, cookies, flaky pastries, bread. Just food. Lots of food. Mainly sweets.

Posted 03 June 2013 - 11:35 AM

I have appealed the denial and just got word this weekend that they won't accept my appeal. Since it is listed in the "Benefit Exclusion" section of my contract, they say they can't cover it. The appeal was actually for NuVigil because my neurologist wants me to be able to try it since it's the preferred treatment (which she explained in a letter we sent with the appeal). They said that NuVigil is a stimulant and falls under that benefit exclusion, so any stimulant I try to appeal will have the same result. The exact wording in the benefit exclusion is, "Non covererd prescription drug benefits include drugs for alcohol or substance abuse or mental illness." The next step I guess is to submit another appeal (?) and go in front of the panel. They also provided an address if I want to file a complaint with the Indiana Department of Insurance, which I do because categorizing stimulant medications under the umbrella of "mental illness" seems very inaccurate to me. ProVigil and NuVigil are stimulants, yes, but as far as I understand they were created for use by patients with sleep disorders (not a mental illness). The other stimulants were created for patients with ADHD (also, not a mental illness), which I would consider a behavioral disorder and I thought the medical profession considered it as such, too. If you really wanted to, you could call any illness a "mental illness," but there are distinctions for a reason and it's to the detriment of patients like us that they try to lump different medicines into one broad category. Ugh. I'm tempted to just file the complaint, wait until I move to NYC to get new insurance, and just pay the full price for meds until then.



#4 CarlaWilS

CarlaWilS

    Member

  • Members
  • 30 posts
  • Gender:Female
  • Location:Indianapolis
  • Interests:Food! Music, singing, writing, movies, reading, baking, chocolate, cookies, flaky pastries, bread. Just food. Lots of food. Mainly sweets.

Posted 03 June 2013 - 11:36 AM

Also, thanks for the info on the different groups. Is there any way that you can make sure when getting a new policy that your group will cover those prescriptions? It seems especially tricky with N since the Adderall may stop working after a while and I'll have to try a new medicine. I just want to make sure that any medicine I may have to take will be covered.



#5 josh3

josh3

    Member

  • Members
  • 1 posts

Posted 03 June 2013 - 04:11 PM

I would not recommend accepting their denial of your first appeal as a final answer. You should have additional appeal(s) available and their denial is completely ludicrous. However depending upon your plan (group plans may be under ERISA which provides strong protections for the insurers and employer) your further appeals may be limited, and once you exhaust your administrative appeals you may not be able to add anything else to support your position, no matter how vital or important, even if you file legal action. So before filing any other appeals, I'd recommend fully research your plan and the law(s) applicable to it.

 

With that being said, refusing to cover Nuvigil as treatment for Narcolepsy due to a mental health exclusion is ludicrous.

First, as everyone has said, Narcolepsy is not a mental health disorder.  (http://www.google.co...olepsy site:gov)

 

Secondarily and perhaps most important for your appeal,  Nuvigil and Provigil are approved by the FDA for OSA, Narcolepsy, and Shift Work Disorder. Also, the FDA full prescribing information warns in bold print  that it is not approved for children for any medical condition, and a clear contraindication, due to severe effects in clinical trials.  Though doctors can prescribe to adults for any reason they see fit, I'm not sure how your insurance company can deny it when the approved indications are medical conditions (not sure how SWD/circadian rhythm sleep disorder would be classified).  (http://www.drugs.com...tml#indications and http://www.drugs.com...tml#indications)  (In fact, here are some documents from Anthem's website indicating what indications they cover for Provigil and Nuvigil. (http://www.anthem.co...pw_b156244.pdf, https://secure1.anth...pw_b156299.pdf, http://www.anthem.co...er=ahpprovider, http://www.anthem.co...refer=ahpfooter)

 

Finally, if they are right on the previous two, might be worthwhile to read up on mental health parity in Indiana and/or New York to see if that may provide coverage.  Again, depending upon if your plan is/will be covered by ERISA, the laws can vary from plan to plan.

 

As someone else mentioned, your doctor's office may be able to help.  And in the meantime might want to check out the patient assistance plan (http://www.cephalonc...DoIQualify.aspx), though I'm not sure about the "cares" part considering the amazing lengths they've gone to to artificially keep the cost of Provigal exorbitant and even increase it to drive patients to Nuvigil prior to the deadline in their collusion with the generic drug companies.

 

 



#6 Hank

Hank

    Member

  • Members
  • 1,327 posts
  • Gender:Male

Posted 03 June 2013 - 04:32 PM

I have appealed the denial and just got word this weekend that they won't accept my appeal. Since it is listed in the "Benefit Exclusion" section of my contract, they say they can't cover it. The appeal was actually for NuVigil because my neurologist wants me to be able to try it since it's the preferred treatment (which she explained in a letter we sent with the appeal). They said that NuVigil is a stimulant and falls under that benefit exclusion, so any stimulant I try to appeal will have the same result. The exact wording in the benefit exclusion is, "Non covererd prescription drug benefits include drugs for alcohol or substance abuse or mental illness." The next step I guess is to submit another appeal (?) and go in front of the panel. They also provided an address if I want to file a complaint with the Indiana Department of Insurance, which I do because categorizing stimulant medications under the umbrella of "mental illness" seems very inaccurate to me. ProVigil and NuVigil are stimulants, yes, but as far as I understand they were created for use by patients with sleep disorders (not a mental illness). The other stimulants were created for patients with ADHD (also, not a mental illness), which I would consider a behavioral disorder and I thought the medical profession considered it as such, too. If you really wanted to, you could call any illness a "mental illness," but there are distinctions for a reason and it's to the detriment of patients like us that they try to lump different medicines into one broad category. Ugh. I'm tempted to just file the complaint, wait until I move to NYC to get new insurance, and just pay the full price for meds until then.


If they are saying non covered for alcohol or substance abuse or mental illness, then it seems you should be successful with an appeal.

You and your prescription do not fall into those categories.

Your physician's office needs to lead the charge on your appeal with a clear letter explaining the medical basis. A physician can call the medical director of a plan. They do this stuff all the time, so the burden does not need to fall on you. It really should be a matter of a few phone calls from the right person with the right information to Anthem. This is generally called a prior authorization and should do the trick.

You do not need to re-invent the wheel with this- call your doctor and let them do what they know how to do. They have the responsibility to you as their patient.

#7 CarlaWilS

CarlaWilS

    Member

  • Members
  • 30 posts
  • Gender:Female
  • Location:Indianapolis
  • Interests:Food! Music, singing, writing, movies, reading, baking, chocolate, cookies, flaky pastries, bread. Just food. Lots of food. Mainly sweets.

Posted 11 June 2013 - 08:25 PM

Josh3, I referenced those documents from Anthem's website that you linked to when I was on the phone with customer service representatives trying to get an answer for why they were refusing to cover every prescription. I was essentially told that Anthem could decide to not cover something at any time, for any reason, and not have to notify me. So, apparently this benefit exclusion gives them the right to do that and takes away my right to argue against it because my mom signed the contract.

 

Hank, my first reaction to learning that my prescriptions wouldn't be covered was to do a prior authorization. I thought that would fix it because the information in my formulary says that those medicines are covered with a prior authorization. They refused to even review the prior authorization because of this benefit exclusion. In the appeal I just sent, my doctor wrote a note saying that I have clinically definite narcolepsy and Provigil and Nuvigil are the preferred treatments for N. We also sent my sleep study results and appointment summaries from before and after my sleep study. My sleep study is pretty conclusive--slept during all naps, mean sleep latency around 3 mins each nap, dreamt each time, no sign of sleep apnea--so I thought that would be the best ammo we have. Still, no dice.

 

As far as I know, my only option right now is to go in front of the panel. I've read that most of the time, if you keep bugging them, the insurance company will eventually give. I just don't know if I have the energy for it. I have an appointment with my Dr. next week, so I'll see what she thinks we should do next.

 

Thanks for your help, guys :)