Modafinil

[its2much]

Just wondering how many of you have been able to get approval/prior authorization for this drug from your insurance company? Has anyone had their doctor contact the insurance company and then received a denial?

[alanpgh]

Provigil (Modafinil) has generally been easily available in Western Pennsylvania from Highmark BCBS and UPMC insurance for many years. Originally, each person had to appeal each denial. Then, the main neuros made the case across the board that Provigil is appropriate after Amantadine doesn't work for MS Fatigue. Now it's generally available.

I don't understand why there is such variability across the U.S. and with different insurance plans?

Is it availabile on Medicare?

Any comments are appreciated.

Thank You,
Alan

[jessiesmom]

Approval for Provigil

I am sorry that you seem to be having difficulty getting your insurance to approve Provigil. I believe the problem is that the FDA has approved the use of the drug for only 3 specific diagnoses: 1. Narcolepsy 2. Obstructive Sleep Apnea and 3. Shift Work Disorder. Unfortunately the debilitating fatigue caused by MS doesn't fit into those categories. Obviously doctors prescribe drugs for off-label uses all the time. I know a number of people who post on this discussion board take it. It seems to me that with proper documentation and the support of your doctor, you should be able to successfully appeal the denial with your insurance carrier. I wish you the best of luck.

[alanpgh]

Appeal Letters from the National MS Society

This link to sample Insurance Appeal Letters from the National MS Society might be of help:
http://www.nationalmssociety.org/Nat...rs-Toolkit.pdf

Best Wishes!

Alan

[SNOOPY]

When I went to fill my prescription for Modafinil (Provigil) the insurance company denied coverage, the Pharmacy let my Dr. know that same day, Dr. called the insurance company and Modafinil was approved. My prescription was ready for me to pick up the day after it was denied.

[JerryD]

I think that this discussion is important to the MS community . It makes me absolutely furious that the FDA, law enforcement, the NMSS, the health care insurance companies and every other MS related organization treats this drug like it is heroin ! All of the aforementioned know, full well, the usefulness of these drugs in the treatment of MS. To deny access to an MSer' is cruel and inhuman !
I take Modafinil and I have been for several years. At first, I was denied by my insurance company but my neuro appealed. And now, there is no push back .

[alanpgh]

This is Great News Snoopy!
I'm glad you were quickly approved.

it seems the insurance companies are giving us some slack, compared to many of their past practices.

In my experience, the NMSS has always been supportive of the science behind Provigil being effective for MS Fatigue. This is exemplified by the availability of sample appeal letters for Provigil and many other treatments.

Thank You all for your comments.

Alan

[msgijo]

Oh my insurance approved it. But they only pay like 5% of the cost of it. While it worked OK when I started on it the longer that I took it the less effect it had, and now it is simply not worth the cost to me to take it.

Doctors are dead set against trying any ADD type drugs so I am just tired all the time. It's normal .

[alanpgh]

For me, Provigil has made a transformative difference in reducing my fatugue level and improving my quality of life.

Interestingly, Nuvigil (slow release Provigil) did not work for me, but Provigil does work. For some people, the opposite is true. Each person is different.

Good Luck Everyone!

Thank You for your comments!

Alan

[pennstater]

I had it denied for years, even following neuro appeal.

My neuro would prescribe double the dosage I needed, When I only needed a 100mg per day, he would also prescribe it 2/x day instead of 1/day. This was his idea because he was furious as well that they would not cover. The

So the one 90 day Rx lasted me 360 days for the 100mg dosage. I used a pill cutter and cut each week.

When I needed a higher dosage, I wound up ordering from Canada. The pill was actually manufactured in India. I found it helped clear some cog fog for me, but not the physical fatigue.

When I stopped working and switched to husband's medical plan, it was a different insurer. So again, denied, neuro appealed, and this time, successful. When I started again filled in US, both physical and cognitive were better.

So possibility Rx shipped by Canadian pharmacy not exact same formulary or could also just be that since not working, fatigue in general is somewhat better.

It does suck that here in the US, insurers have so much control over our meds. Until the FDA is pressured into listing MS Fatigue as usage, we are at our insurer's mercy.

[hitdog042]

Just wondering how many of you have been able to get approval/prior authorization for this drug from your insurance company? Has anyone had their doctor contact the insurance company and then received a denial?

I am on Medicaire part D. I never had a problem but provigil didn't work for me. Switched to Adderall and also had no insurance issues. I'm in Ohio. No pre auth or anything.

Only time that happened to me was with testosterone and the approval took like a week.

[jreagan70]

Until the FDA is pressured into listing MS Fatigue as usage, we are at our insurer's mercy.

That isn't how it works. The FDA doesn't choose what a drug is used for. The use is chosen by the patent holder/manufacturer in their new drug application.

The use is chosen by the applicant. The applicant presents clinical data that, it is hoped, demonstrates that the drug is safe (which is a relative term) and effective for the use being applied for. The FDA then approves or rejects the drug for that specific use. The FDA has no influence over what use is chosen, or the use the drug is approved for, other than to agree that the drug is safe and effective for that use.

Because drug trials cost multi-millions of dollars, drug companies limit the number of uses applied for in order to keep the cost of the trials down. If there is the potential of profit for other uses, the company will then run more clinical trials for the second purpose. It has to apply for the additional use(s) separately.

An example of this is Ampyra, which is approved only to increase walking speed. There doesn't appear to be any potential for profit in testing and applying for another other use.

Another example is Tysabri. After it was approved for MS, Biogen did separate trials and applied separately for its approval for treatment of Crohn's disease. Obviously there was the potential for profit in using it to treat another disease.

The specific use(s) for a drug is part of the drug's labeling. The FDA doesn't forbid use of drugs off-label, but it forbids drug companies to advertise or in any way promote off-label uses.

Once a drug loses patent protection and goes generic, there's no motivation for anyone to do clinical trials to get a new use approved. They can't get another patent for that use because it's the same drug, and there's no way to make back the money that would be spent on drug trials.

Nor does the FDA have any influence over what drugs insurance companies put on their formularies or what uses of the drugs the insurers cover.

So that's why the FDA can't be pressured to add an approved use to force an insurer to cover the cost of a drug. They don't control it.

[tahoeteri]

I had no problems with coverage

When my Neuro prescribed 100 mg Modafinil, I had no problems with the insurance (UHC) covering it and my co-pay was $70. I think he had to tell them it was specifically for MS. The 100 mg had no effect so he upped it to 200mg per day and that helped with my fatigue for a few months but then seemed to stop working. I may be switched to Nuvigil soon (Dr appt next week, so we'll see). As stated by someone above, it is a lot to pay for a drug when it seems to not be working anymore.

Teri

[AriD]

I had a lot of trouble with insurance approval. First time they denied it and my neurologist filed a lot of paperwork and I was able to get it for a year. This past January they denied it again even though I was taking it and it was really making a difference for me. They said I needed to have sleep apnea or narcolepsy to get it approved this year. Ridiculous!

Anyway had a sleep study to try to get some proof for insurance since I have had sleep issues of waking up every 90 minutes every night. Well I have sleep apnea so got the Modafinil back. Didn't believe I had that and still not sure since I still wake up every 90 minutes with the mask on. Just had second study in the hospital which didn't show sleep apnea so seeing sleep neurologist again this week to decide what's going on.

I'm afraid though if they take back the diagnosis I'll lose the Modafinil which will mean tough days ahead. I just had to come off Ampyra two weeks ago because I'm having seizures now. Without both not sure if I'll get back to work after I recover from this relapse.

Sorry for going off track but yes some insurances can be real tough on allowing Modafinil for MS. Good luck with the battle!

** Moderator's note - Post broken into paragraphs for easier reading. Many people with MS have visual difficulties that prevent them from reading large blocks of print. **

[alanpgh]

Where do you live, and what is your insurance?

Many insurance plans cover Provigil for MS if you appeal.
Here are the appeal templates from the MS Society:
http://www.nationalmssociety.org/Nat...rs-Toolkit.pdf
(Thank you MS Society for the appeal templates!)

In your case, perhaps the Sleep Apnea diagnosis will help.

Please keep us updated.

Best Wishes!

Alan