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Provigil Denied By Insurance-Now What?


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#1 CatLady

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Posted 20 November 2013 - 06:49 PM

Got notification today that my Provigil script was denied by insurance because  I didn't meet the criteria for sleep apnea.  Well, no duh!  That's because I don't have sleep apnea, I have narcolepsy!  Anyone else run into problems with their insurance approving their meds?  Feeling a little frustrated right now.     :mad:  



#2 hbananas

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Posted 20 November 2013 - 08:04 PM

It took my doctor three times to get me approved for Nuvigil.  Different drug, I know.  She had to prove that I wasn't sleepy in the daytime due to poorly treated sleep apnea.  What tipped the scale was an overnight polysomnogram showing that my CPAP effectively prevented apneas and hypopneas, followed by the MSLT that showed objectively that I really was falling asleep too easily in the daytime even after a decent night's sleep.  I think the doctors don't know which hoops they are going to be made to jump through until it is denied the first time.  I received the denial from my insurance company that listed several criteria, and I met every one of them.  It just hadn't been demonstrated to them yet.  When I got the second denial, I called the insurance company to make sure it wasn't just a repeat of the first one, and that I had to either have the medicine or quit my job.  A few hours later, the doctor's office called me to tell me it had been approved.  I don't know what magic took place in between.



#3 ironhands

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Posted 20 November 2013 - 08:34 PM

how much is it out of pocket?  I know up here it's not too expensive, but we have regulations when it comes to what they can charge for medications



#4 CatLady

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Posted 20 November 2013 - 08:48 PM

hbananas:  Three times?  Wow.  That's a lot of red tape, but it gives me hope that this may work out for me yet.  I had an PSG and MSLT that showed I didn't have sleep apnea but did have N, so maybe the Dr.'s offices needs to submit that or something.    I would think that N would have to be a condition that is covered by insurance, but I've been wrong before.  Just ask my husband.  :P

 

ironhands:  I'm not sure of the exact cost of out-of-pocket, but the figure I have seen kicked around is like $1400 or so a month.  Ouch.



#5 ironhands

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Posted 20 November 2013 - 09:48 PM

1400?  that's insane!  I think someone told me it's only 3-5$ a pill here



#6 Ferret

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Posted 20 November 2013 - 10:16 PM

It is insane. Completely insane what Americans have to pay for medications and the hoops they have to jump through to even get a prescription. Anarchy anyone?

Here's a comparison. I live in Mexico therefore the only medications that I need a prescription for are narcotics or antibiotics.

The name for Modafinil (Provigil) in Mexico is Modiodal.

I'm looking at the box I just bought...28 pills, 200 mg. each and the embossed price on the end of the box (which is the MAXIMUM price that it can be sold for) is $1507 PESOS. At 12.5 pesos to the dollar, that's about $120.00 American and the pharmacy where I buy it gives a 20% discount.

In other words, since I break the pills in half and only take 100 mg. a day....my meds cost under a hundred American dollars for 56 days....and they are imported from the U.S.

 

Americans really should start getting very pissed off at what they are having to pay. Soon. Insurance companies who don't understand medicine should be put out of business.



#7 doinmdirndest

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Posted 21 November 2013 - 03:03 AM

the medicare list of covered meds has maximum amts. that will be covered.  other meds have no mg/d maximum under medicare rules..   w/nuvigil it's a 400mg/d limit. no limit for Adderall or other amphetamines.

 

I've contended the amphetamines are well tolerated in very high doses by a scant few of us here and elsewhere for three years.  many do not altogether concur; I think my conclusion is correct, so:

 

-the optimist in me finds reassuring the apparent allowing for high dose amphetamine prescribing the feds have incorporated into the medicare rules.  

 

my thought is like "wise men and women hold the job, thank goodness they are at that station, and not persons of the dominant paradigm's medical position on EDS treatment with traditional stimulants.        and thank goodness they are able to understand that the need for a low dose maximum on these meds is based on myths."

 

however.....

 

-the pessimist in me (who seems to gain ever more ground as I get older, while the optimist fades) finds it highly likely that the absence of a medicare coverage doseaging limit on Adderall is the product of a beurocrat's oversight, as opposed to his/her wisdom. 

 

...........and that if I huff and puff long enough and hard enough about injustice done to PWN in whom nuvigil is well toletrated (does not include me) being denied-via inability to private pay-optimal treatment if/when mg/d amounts of this med are indicated in amounts above the 400mg/d maximum covered dose, (1-1.5 g/d was needed for me to hack 1 day's work when I was prescribed nuvigil @ 400mg/d; mandatory job holding forced my exceeding the prescribed mg/d taken.  any amount of nuvigil causes severe mental lapses/hallucinations/dehydration in me.) and that the feds should remove the limit they are going to do nothing of the sort.............but they may impose a maximum covered amount on Adderall.

 

.........  i'm going to shut up now.



#8 doinmdirndest

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Posted 21 November 2013 - 06:53 AM

 Anarchy anyone?

 

 

anarchy? yes, please.  thank you.     "there has never been a government that was not a liar, an extortionist, a murderer, and a theif " -I don't remember the author's name.  might be Anatole france



#9 Asksuzan

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Posted 23 November 2013 - 11:55 AM

Keep pushing back! Have Doctor wright an appeal.

#10 CatLady

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Posted 27 November 2013 - 06:49 PM

So the Provigil was denied a second time due to the fact that the insurance still thinks that I need to be on a CPAP before I am prescribed medicine, even though I didn't have a diagnosis of sleep apnea.  Sigh.  The good news, however, is that the doctor's office gave me a month's supply of samples of Nuvigil to take while they get this insurance mess sorted out.  I'll be taking the first one on Friday.  Kinda nervous about a new medication, but hopeful and excited too.



#11 ironhands

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Posted 27 November 2013 - 11:24 PM

your insurance company needs serious inspection, a CPAP is as useful to narcolepsy as BEEPs on a bull.  you're being prescribed provigil for N and NOT for general EDS



#12 CatLady

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Posted 05 December 2013 - 06:35 PM

Update time:  My insurance finally-FINALLY- approved the Provigil, but only for three months.  I won't go into the gory details, but it was much more complicated than it ever should have been.  However, there is a new issue.  The doctor's office gave me a month's worth of samples of Nuvigil to tide me over until the Provigil was approved.  I started taking it last Friday, and everything was going well until yesterday, when I broke out in hives.  Obviously I stopped, and I am now wondering what to do.  Has anyone restarted a med that they had a reaction to, but in a lower dose?  I have a dr appointment early next week, so I am certainly going to discuss all this with him, but wanted to know other people's experiences.  It seems like such a shame that after all this, I may not ever be able to take the meds.



#13 Ferret

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Posted 05 December 2013 - 11:02 PM

Wait until the rash is gone...shouldn't take more than a couple of days. If it gets worse, even after stopping the Nuvigil, get yourself to Emergency PRONTO.

Then, do NOT start back on the Nuvigil...even if you were going to go back on the Nuvigil you would want it to be a different lot number. You never did say what strength you were taking or frequency.

 

Honestly, I would wait to see your Doctor anyway before starting back on anything.  Here are some points that you may want to raise in that discussion...

1) are you getting REAL Provigil made by Cephalon?...or Provigil made under license to Cephalon by somebody else?...or generic Provigil made by God knows who and God knows where?

2) starting at a low dosage and increasing it SLOWLY may be more prudent given your reaction

3) check for any cross reactions with ANY other medication or supplement that you're taking (even something like a cold medication)

4) Give him the information taken from the Nuvigil blister pack but make sure you keep a copy for yourself.

 

I take Provigil but experienced a bad reaction with a particular lot number...I let the rash clear and started again with a different lot number and have experienced no problems since.

Please keep track of everything to do with ANY medication you are taking...lot number, expiry date, date of purchase, purchased from where, made by...etc.................It's worth the five minutes to do this in case of reactions. For the past couple of months, I've been buying my Provigil based on TWO pieces of information...the lot number I don't want and the lot number that I do.

 

Here's hoping that it will be better from now on. Best of luck.



#14 Hank

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Posted 06 December 2013 - 12:37 PM

Just a comment in regard to lot numbers:

 

Lot numbers really have no bearing on the effectiveness of drugs. The process, which is regulated by the FDA, is  so precise and consistent that there is virtually no difference between lots.

 

Of course, there can be very rare problems with potency or contamination, which can be tied back to a certain lot number. But this is very rare.

 

Generics are allowed to vary about +/_ 10% from the name brand in effectiveness or potency. "Chemist" would know more about this than me.

 

With a rash, for example:

It could be a physical response to the medication- side effect. Sometimes side effects diminish and sometimes they get worse.

It could be a rash that would have occurred without the medication- just a coincidence- maybe a food allergy.

 

In the case of Provigil and skin rash- it can potentially be very serious and you should contact your doctor before continuing with it. It is a big black box warning in the prescribing information for Stevens Johnson syndrome. Be careful with this before taking again without your docs direction.



#15 Ferret

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Posted 06 December 2013 - 02:56 PM

Hank said "Lot numbers really have no bearing on the effectiveness of drugs. The process, which is regulated by the FDA, is so precise and consistent that there is virtually no difference between lots."

Precise?? Consistent?? Yeah right...that's why Ranbaxy is no longer allowed to export drugs to the U.S.
The FDA is simply not able to control everything, everywhere. And that is also why I receive an e-mail once a week of drugs that the FDA has recalled or pulled because of contamination or other problems....and those are just the ones they've caught.
And more...

http://www.wanttokno...utdrugcompanies

#16 tis91

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Posted 07 December 2013 - 03:56 PM

As I have been treated since I was young for ADD, by means of amphetamines, I know that Culinary Insurance requires the doctor to fill out a "pre authorization" form. Might look into that. 



#17 ruthie s.

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Posted 09 December 2013 - 11:09 AM

I wonder if you could go to a psychologist, show them your narc. diagnosis & discuss trouble focusing, then have them prescibe adderall. ?? Every insurance I've had has always covered Adderrall - which, I originally was prescribed for "ADD" symptoms. It changed my life. Never knew I had narcolepsy, but the Adderall gave me 100% of the wakefulness I had always only "dreamed" about, with no side effects (until yrs later, when the root problem - which I has now been discovered in the sleep lab as abnormal SLEEP! - inevitably needed to be fixed)...... Provigil btw,, I tried once, prescribed by a fam. doc., and it made me feel yuck/ick on top of NOT even doing the trick. Would rather keep sleeping than take that stuff. Just sharing my experience of it.

#18 CatLady

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Posted 10 December 2013 - 07:13 PM

Talked to the doc today, and no more Nuvigil/Provigil for me, which is a shame because it really seemed to help until I got the rash.  So I have prescribed Ritalin instead.  I only know of this as a treatment for ADD/ ADHD.  Anyone have any experience with it?



#19 ironhands

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Posted 10 December 2013 - 09:17 PM

in children, ritalin acts as a depressant, so quite useful for add/adhd as it'll slow them down, but in adult, ritalin is used a stimulant.  i was on it a while to combat the EDS/sleep attacks I was getting with cipralex.  it made me really irritable.



#20 Ferret

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Posted 10 December 2013 - 10:11 PM

Sigh. I guess time will tell. For some people Ritalin is wonderful. I was the wicked witch of the west on it and, according to my hubby, it totally changed my personality. I became overly aggressive, combative and very short tempered. Since I'm opinionated anyway, it was a recipe for disaster. I will stand my ground but I was deliberately picking fights.

Now, do keep in mind that the dosage was 4 times the max allowed now and I was also taking Tofranil (imipramine) for the cataplexy...we're talking back in '86

Anyhooo...try the Ritalin...but please warn your significant other to keep an eye out for personality changes. Actually, anybody's S.O. or really good friends should be observant of any changes when any med is started or changed.

Best of luck!