I’ve written before about my annual pre-authorization hassles for Provigil®.  You can read more in “MS Medications, Insurance Coverage and 2 Ounces of Gold“.

This year I learned about a new tool.  It’s called a “plan sponsor override“.  And, in my experience, it works.

Here’s how it worked.

First, Provigil is not a Food and Drug Administration-approved medication for the treatment of Multiple Sclerosis.  Many medications used in the treatment of Multiple Sclerosis are not FDA-approved for MS.

While the injectible medications like Copaxone®, Avonex®, Betaseron®, etc. were designed for MS and have been tested and approved by the FDA for treatment of Multiple Sclerosis, Provigil has not been.  However, Provigil is commonly prescribed for MS patients because neurologists find it helps with fatigue, one of the most common symptoms of Multiple Sclerosis.  Another example of an “off label” prescription is Aricept®, which is FDA-approved for the treatment of Alzheimer’s.  Neurologist often prescribe it for MS patients to aid with memory and cognitive difficulties.

It may be too simple, but I think about it like this: imagine that Pepto-Bismol® required a prescription (it doesn’t … we’re imagining).  Imagine, too, that it had been tested and was FDA-approved for treatment of nausea, but not for heartburn.  Your insurance company would cover your prescription if you had nausea, but would decline it if you had heartburn.  Even though, it is highly effective against both!

That’s how prescription coverage works.  Insurance companies use the FDA as their excuse to deny coverage.

Second, my health insurance company outsources the medication and prescription benefits to a third company, Medco, a $20 billion dollar, public corporation listed on the NYSE as MHS.  In their efforts to return value to shareholders, Medco denies coverage for my wife’s medications prescribed by her neurologist for non-FDA-approved purposes.

On one hand, this practice makes sense (from a capitalistic perspective).  Why should an insurance company pay for medications being used for purposes not approved by the U.S. Food and Drug Administration?

On the other hand, who wants to assume a government agency knows as much about the treatment of a disease as neurologists do?

Looking at both hands, I believe Medco is more interested in shareholder value than in patient care.  They’re a public corporation, they have to be.

Anyway, after several denials, appeals and denials, I finally heard a Medco employee say something I had never heard, “Perhaps you should request a plan sponsor override.”

“What’s that?”, I asked.

“Ask your insurance company to override our denial,” she replied.

“That’s it?”

“We’ll honor it.”

I called my insurance company and spoke with several people until they found someone who could speak to me about requesting a plan sponsor override.  Long story, short: I faxed my insurance company the last appeal letter I had sent to Medco.  Two days later Medco agreed to cover the medication.

Caregiver Tip:  If prescription coverage is repeatedly denied by a third party, ask your health insurance company about a plan sponsor override.

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