Another Coverage Review

After spending almost an hour on the phone with our pharmacist, my wife’s neurologist’s office and several employees of our health insurance company, I took a break before writing a letter to appeal the insurance company’s decision to deny the neurologist’s appeal of the insurance company’s refusal to authorize payment for another year. I wrote a letter requesting a coverage review.

Caregiver Tip: Always make and keep detailed notes of dates, times, names, comments, phone numbers, everything that happens, and keep copies of all correspondence when communicating with insurance companies. Good notes will make it easier the next time the issue arises.

Each of us in this phone and letter dance knows Provigil is FDA-approved for narcolepsy. It is not FDA-approved for Multiple Sclerosis.

However, studies by the drug’s manufacturer, in addition to consistent reports of MS patients, and the clinical experiences of neurologists all support that Provigil is indeed an effective treatment for Multiple Sclerosis-induced fatigue when taken in small doses.

My insurance company automatically takes the financially prudent way out. “It’s not FDA-approved for Multiple Sclerosis. You must submit your appeal in writing,” and, “if you make a voice appeal and are rejected, there is no additional appeal available for you.”

The neurologist, the pharmacist, the insurance company and I have done this annual dance a couple of times now, but this year something has changed. This year the insurance company denied the doctor’s appeal and asked me to request a coverage review of the decision. I wonder what convincing evidence I might provide that the neurologist cannot conjure? (In a later post, I’ll share my appeal letter as a sample of what insurance company’s seem to look for when they perform coverage reviews.)

I’m told I may wait up to 30 days for the insurance company’s final decision regarding this coverage review. But it won’t be that long. One thing I appreciate about my health insurance company is that they work quickly when doing coverage reviews.

And in practical terms, I know this coverage refusal was probably an automated response. One of the insurance company’s computers is probably programmed with this simple logic:

If prescribed medication is FDA-approved for this disease then approve coverage, else decline coverage.

Fortunately, I can speak with real people when the computers say, “no”.

In the meantime, I’ll buy the Provigil from my pharmacist ($439.16 a month) while the insurance company decides to cover this medication which so effectively treats my wife’s MS-induced fatigue. The thought of paying an additional $5,269 per year for a single medication gives me pause and I wonder how long I could afford to do it.

Instead of fretting about that though, I remember I live in a God-graced universe. An illogical, but faith-filled, approach to managing concerns about things I can’t control.

From my own experience, I offer these tips for coverage reviews:

  • Be friendly and polite when you speak on the phone.
  • Keep detailed notes of everything (names, phone numbers, fax number, addresses, etc.)
  • Use the Internet to find research that supports your request for coverage.
  • Consider that initial coverage decisions are often computer-generated. Talk to people.
  • Maintain a good relationship with your pharmacist.
  • Avoid fretting about potential problems. It will wear you down.

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