Category: <span>Health Insurance Coverage</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

The business office of our local hospital volunteered that they offer a 20% cash discount for MRIs. (I did not ask, but I imagine it is available for other procedures, too.) The cash discount doesn’t surprise me. The 20% certainly does, though.

Simply stated, if one pays for an MRI at the time the work is done it costs 20% less than if one pays it out over time. That’s really nice. A 20% cash discount is a big discount. You won’t get that large a discount from many businesses.

In fact, from a management perspective 20% is a huge discount! (I know these financial matters are an odd topic for a blog written for MS caregivers. Follow me a bit, though, and I’ll come back to an important tip for MS caregivers. A good book for those who would like information about the financial formulas used to calculate a cash back discount is, “Working Capital Management: Strategies and Techniques”.)

Cash discounts are usually offered for one of three reasons; to attract customers away from other businesses (not an issue in our small town where the local hospital holds a monopoly on many services), to save a few dollars (if the cash discount is less than the amount paid to a financing firm), or to help a hurting cash flow problem. In any of these cases, 20% is a huge discount. That amount does not make financial sense when viewed from a classic cash management perspective, but … I don’t know about the hospital’s business. It must make sense to management if they’re doing it.

Like me, you may not have considered asking for a cash discount for medical services. I was surprised, but now realize I shouldn’t have been. Healthcare is a business like any other.

Caregiver Tip: Medicine seems to become more and more like any commodity business as time passes. Therefore, it makes good sense to ask for a cash discount whenever you purchase medical services. The worst that can happen is that you may be told, “I’m sorry, we don’t.”

However, if they do, you can save a good bit of money … especially at my local hospital.

Health Insurance Coverage

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.

Health Insurance Coverage