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Old 10-29-2019, 02:11 PM
Suebee Suebee is online now
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Join Date: Mar 2015
Location: Houston, TX
Posts: 457
Default Insurance frustration/ appeal/ meds/ caused undue distress

Anyone else having trouble getting modinifil lately? This med is the reason I can work or go out to grocery shop or see my kids in a event. Ms fatigue makes me feel like I'm on a death March and modinifil allows me some relief. BUT Yesderday, my refil prescription for modinifil was denied by health insurer because it exceeded 30 quantity number of pills per month. I got no prior notice and it took 2 phone
calls for over an hour to be told 1) my plan doesn't allow, insurer can't say when change happened or rationale. 2) Instructed to appeal by phone- i explained that I need pills to" function physically and cognitively" but as soon as customer rep typed it in, she immediately said my request was denied and I needed to appeal this denial by letter or fax and insurer gets 14 days to decide.
I pointed out that I get only 100mg strength and the higher 200 mg 30 day supply is allowed under my plan, but that these pills can't be split in half. So I asked under what rationale is my weaker strength prescription being limited???? THERE IS NONE! Other than it apparently costs insurer x amount per pill quanity. Why are insurers allowed to make such decions, which are not based on health of patient, treatment plan of doctors, or patient quality of life? What board room did this decision get made in and by whom? I'm so frustrated that my precious energy resources will now be used on a pointless exercise to appeal 30 quantity monthly limit for modinifil which is essentially an arbitrary limit that has no rationale other than monetary.
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Old 11-02-2019, 08:38 PM
Suebee Suebee is online now
MS Whisperer
 
Join Date: Mar 2015
Location: Houston, TX
Posts: 457
Default Update / continued question about modafinil coverage

My husband called today to verify that More than 30 modafinil pills a month are not covered under my bcbs anthem coverage. Initially the insurer rep incorrectly told us to file a renewed request For pre authorization with documentation from doctor but after pushing and waiting on hold awhile the customer rep conceded that I could only get a quantity of 30 pills a month... rep had no info about why... but did throw out there it was A controlled substance. I also got denial letter today citing quantity rule under “policy rule 1599” which is available upon request only. A search of the web only uncovered similar Tufts recent change in policy, limiting quantity of modafinil to 180 pills for 90 days. Similar to Anthem, It doesn’t list mg strength. Regardless tufts covers 2 modafinil pills a day vs. Anthem’s 1 a day. Anyone else getting changes to coverage??? This is exactly why drug trials need to be funded for MS. Use of modafinil “off label” puts MSers at risk of the whims of insurers. Anyone have a clue as to what is pushing this change?..

Here is tufts current policy on modafinil
https://tuftshealthplan.com/document...elines/nuvigil
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express scripts, insurance, insurer, modinifil, multiple sclerosis

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