Me vs FDA Guidelines and Insurance

I am so glad Blogger is back up. It's taken me several days to write this post as I've been doing research as well as trying to wrap my head around the information.

I've been on a drug for sleepiness for the past several years. I have borderline obstructive sleep apnea which my only symptom is sleepiness. Years back, the doctor put me on Provigil to help the sleepiness. Before having the drug I would sleep constantly and I couldn't remember alot because I was tired and sleepy. After I started taking the drug, I became more alert and my life was more productive.

When I first started this drug, I had to go through the red tape to get it because it was new, it was on a lower tier and my diagnosis didn't match the FDA requirements. However my doctor sent the preauthorization and it was approved. I moved on my merry way.

2011 rolls around and I get a formulary that shows that particular drug (PROVIGIL) was not covered but a newer one replaced it (NUVIGIL). NUVIGL Is in tier 3 so I had to get it preauthorized. Okay! I've been there done that. It was denied.

My questions are why have a tier for a drug in the formulary that has to be preauthorized? What gives the insurance the right to tell me or my doctor what I can or can't have medically? What other credentials do they have that my doctor doesn't have to be able to override MY doctor's orders?  These assholes have never met me or know anything about me except when they get my premium, or what the doc has on the forms.

For my first prescription the doc had given me an offer from a sales rep for a free month to try and then another "prescription savings card" to reduce the price of what I had to pay. I found out after my free version, the prescription savings card was void because of my insurance. GO figure.

I took the free month trial and it worked so I attempted to refill it. However, my pharmacy called me and said they ran it through but my insurance denied it. I said well gee, why would the insurance pay for the "free' but not refill it.

So I called the insurance and talked to "BRAD" At first, Brad kept saying, "I can't hear you."  I was sorta rambling and he just says, "SHUT UP." I said, "EXCUSE ME! Let me tell you something, I deserve the respect I give you. I understand I sometimes have people have difficulty understanding me but I don't deserve SHUT UP. I AM THE CUSTOMER here. My premium pays YOUR WAGES BUDDY!: He mumbled an apology and asked if he could put me on hold for 3 minutes. He comes back and confirmed it was denied!

I asked him what the next step was. "Brad" told me to call the doctor and ask them to CALL them to give them a redetermination. He told me it could take up to 48 hours to get a decision. So I called my doctor and talked to his nurse and she said she would do it. Two hours later she called and said it was declined again so Doc was prescribing an entirely different drug (ADDERALL). 

So, I researched these three drugs. If you go the websites indicated, Provigil and Nuvigil have almost the same exact indications but Adderall has different indications although one is similar to the Provigil and Nuvigil. Adderall is better known for ADHD, which I DO NOT HAVE..

I was royally frustrated and just put it up for the night because I knew if I called my insurance or doctor's office I would get nothing accomplished for sure because I would have told them to go to hell.

The next morning I called customer service again, repeating what I said yesterday to a "Barbara."  Don't you hate it when you have to call customer support numerous times and have to repeat your story over and over?

I was calm. She said that they only received the preauthorization NOT the redetermination. I told her that the nurse said she sent it and it was denied.. She put me on hold for 4 minutes to get to the 'other' system to recheck that they received it. She comes back and said they never received the redetermination from the doctor.

I said, "Well I don't know what's going on. Because the nurse told me that she sent it." Barbara asked me if I had seen the denial. I said, "NO." So she read it to me. It said, summarizing, that because I didn't have narcolepsy or use any breathing device, etc the request was denied because it didn't follow the FDA requirements. I remember having the same response when I first started the Provigil.

But, I asked her what the next step was. She said, "Your doctor has to send the Redetermination forms to us." I was aggravated.

I said, "You know Nuvigil is supposedly a new drug and almost indentical to Provigil. It just seems Nuvigil was replacing the Provigil. You approved Provigil years ago and I've been on it for years. But then YOUR company decides to change some drugs in formulary. Tell me, what is fair about that?.

She said, "Ma'am, I understand your frustration but there are alternatives like Adderall." That did NOT answer my question.

Reading from my notes I said, " Adderall, a drug with the combination of dextroamphetamine and amphetamine is used as part of a treatment program to control symptoms of attention deficit hyperactivity disorder (ADHD; more difficulty focusing, controlling actions, and remaining still or quiet than other people who are the same age) in adults and children. Dextroamphetamine and amphetamine tablets are also used to treat narcolepsy (a sleep disorder that causes excessive daytime sleepiness and sudden attacks of sleep).

I paused. I asked if she was still with me and she said she was listening.

I continued, "Nuvigil is sleepiness due to one of the following diagnosed sleep disorders: obstructive sleep apnea (OSA), shift work disorder (SWD), or narcolepsy. In patients with OSA, NUVIGIL is used along with other medical treatments for this sleep disorder. NUVIGIL is not a replacement for your current OSA treatment, and it is important that you continue to use this treatment as prescribed by your doctor. NUVIGIL may help the sleepiness caused by these conditions, but it may not stop all of your sleepiness and does not take the place of sleep.

So she tells me that she knews this but I needed to call my doctor to send the REDETERMINATION forms to decide.

I called the doctor's office and the nurse swore up and down she did so the previous day. I told her they didn't have it. She got a little abrupt and said well Doc says to try the Adderall. I told her I didn't feel comfortable using Adderall. I told her there was a chance to get the Nuvigil which was ordered in the first place She relented and said she would do so again.

I suspect she never did it in the first place. She calls me 2 hours later saying that she called the insurance and they said it would take up to 72 hours for the 'board' to determine it. I thanked her graciously.

When I got off the phone and thought about it, I suspect that I was right, she never sent the redetermination like she had said. She calls me 15 minutes later and said the request of redetermination was denied so she was going to mail me the prescription.

My question was what happened to the 72 hours window. How can a 'board' make a decision in less than 15 minutes?

So I called my insurance again. I told the customer rep I didn't wan to talk to any more customer reps and wanted to talk to someone above them and talk to someone to file a complaint. So after being on hold for 15 minutes later a LATASHA came on and told me she was the in the complaints department and we went through the complaint processs which was the same thing, I had to repeat myself. She said she would put it through the board of grievance and it could take up to 60 days.

AN hour later, I got a voicemail because I didn't answer the unknown number. It was LATASHA. She said the board has filed the complaint and the decision stands, they deny my request for the drug to be covered.   

THis was past 5 pm so do tell me how a "BOARD of doctors and nurses" can read my history and the request in such little time?

The next day I got a letter in the mail stating it was denied and the reasons, same LATASHA told me. I still don't buy it. It gave me instructions on how to appeal their decision by asking for a formulary exception.

So I have 60 days from receiving the notice to ask for the formulary exception with documentation proving I need the drug that is not on the formulary. (BUT IT IS ON THE DAMN FORMULARY) It also states although its on the formulary it is denied because it was not under the guidelines of prescribing the drug. 

It is a like a freaking 3 ring circus to fight this but I aint giving up because I know I am right. They just try to make it difficult to appeal it. Unbeknowst to them, they have no idea who they are dealing with.

Wish me luck folks.. There is a fight Me vs. Insurance and FDA GUidelines!