Month: <span>December 2008</span>

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.

Health Insurance Coverage MS Medications

My wife fell this past week.  When she fell, I was in an airplane between Phoenix and Dallas headed for a connecting flight on my way home from the last session of the Faith-based Leadership Institute.  She’s strong and independent, but a part of me imagines she wouldn’t have fallen had I been home.

She fell in a parking lot, scratched the tip of her nose and banged up her chin.  She scraped both hands catching herself.  It wasn’t her worst fall.  That one required stitches above her eye and she broke a finger.

Falls are unpredictable.  She’ll go months and months without falling, but then it happens.

There are several reasons she and other MS patients fall.  In fact, issues with walking are among the most common MS symptoms.

First, many people with MS have difficulty walking or maintaining their sense of balance.  This dizziness or “vertigo” is a common MS symptom.  Vertigo is often related to slow sensory input, inner ear problems or brainstem damage.

Second, the neurological damage caused by MS impacts the patient’s small and large motor skills.  This loss of motor skills called ataxia and it is a well-documented consequence of Multiple Sclerosis.  Related to falling, an MS patient who experiences vestibular ataxia will find it difficult to walk normally unless she can visually monitor her walking movements.  Literally, vestibular ataxia forces one to “watch how they walk”.

Third, neurological damage experienced by an MS patient can impact “proprioceptive capacity”.  (Why do medical words sound so strange? Who makes these things up?)  In short, proprioceptive capacity is about the brain knowing where the body is.

Proprioceptors are sensory receptors in your muscles, tendons, joints and in your inner ear.  They give your brain information about the motion and position of your body.  Of course, they do it by sending messages through nerves to the brain.  Nerves impaired by the effects of MS may be unable to transmit the messages as quickly as necessary.  The brain doesn’t know quickly enough exactly where all the parts of the body are in relation to the environment.

Another reason MS patients may fall is because of “Drop foot“, it’s the common phrase used to describe an MS patient’s inability to keep the toes of the foot from dropping.  This symptom of MS can easily cause one to stumble on flat surfaces or trip when stepping up on a curb.

The National Multiple Sclerosis Society has information about two devices designed to help patients with foot drop.  The link is:

It seems falls are bound to happen, so what does one do about falls?

In areas where falls are more likely, change the environment.  Securely install heavy duty grab bars in showers and tubs and beside toilets.  Use carpeting to help soften the fall.  Avoid creating obstacle courses in your home.  Maintain clear pathways.  If drop foot is a significant problem, explore the information from the National MS Society about the assistive devices.

I know exercise helps my wife.  She has an exercise machine she can sit or stand on and can go as slow or as fast as she wishes.

Here’s what I do to help prevent falls:  I act like we’re dating!  I hold her hand when we walk.  I open doors for her and hold them.  I slip my arm under hers if we go up or down steps.  I carry things for her without being asked.  (I let her carry things when she wishes, too … she can be rather independent!)

Caregiver Tip:

Falls are going to happen.  As a caregiver you can adjust the environment, but you cannot prevent every fall … especially if you’re not present.  If the MS patient you care for is your wife, treat her like you’re always on a date … it helps prevent falls and it’s good for your relationship!

Living with MS Practical Tips