Back to the post Me Vs. FDA Guidelines/Insurance, after I was denied numerous times within hours, I thought it out for a few days and wrote t his letter to appeal the denial. I gave a copy to my doctor to include with his letter. He loved my standpoint. Here is the letter for those who follow and it should give a more understanding. I faxed it to them June 1st and waiting for response.
To Whom It May Concern,
I am requesting for a coverage rule exception,independent review AND/OR a tiering exception for Nuvigil. I am asking you to cover the Provigil or Nuvigil. I was on Provigil for years but this year your company deleted it from the formulary and replaced it with Nuvigil.. I used Nuvigil as a free month trial and it worked, but then your company denied approval. You should have all the documentation from my physician. I have some sleep apnea and if I don't take Provigil or Nuvigil I am sleepy all day and my productivity is next to nil. From what I read, Adderall is more addictive than Nuvigil or Provigil. I have never had as much trouble with you covering a drug before with your company until now.
Provigil was in a Tier 3 drug as Nuvigil is. Same EXACT indications unlike Adderall.
I called your customer service at least 3 times that day at the beginning of May, talking to different people (Brad, Barbara and LaTasha) having to tell them my story 3 times which was redundant. The last person, Latasha gave me instructions to have the doctor's office call for redetermination but informed me it would take at least 72 hours for a decision. My doctor's office did as instructed and less than 2 hours you faxed a denial again to the office.It is highly questionable if your representative even looked and read it at all. I believe the person just looked at my name and Nuvigil, FDA guidelines and without looking at my previous drug history denied it.
What perplexes me is Nuvigil, as Provigil, was a Tier 3 IS in your formularly but it was denied. I know the drug has specific guideline for use of the drugs but I NEED the drug. You do NOT know my whole medical history. How many other drugs have you approved for people that didn't meet FDA-approved guidelines? I'm sure many.
Most perplexing, if the drug is on the formularly the doctor ordered, what gives the pharmaceutical companies and FDA the right to say what the patient needs or doesn't need? I don't understand how the pharmaceutical companies or insurance can override the physician's orders. What kind of certification does the pharmaceutical companies or insurances have that the doctor's don't have? A doctor knows their patient. Pharmaceutical companies and insurance companies have no clue who we are or what we are going through.
I am looking forward to receiving a favorable response from you. If this is not resolved in my favor, I will consider going forth with legal counsel or find another company when it comes time to renewing my coverage.