What happened when I went to pick up Provigil prescription

[Junebug999]

Went to Costco to pick up my prescription.

Clerk: You know this prescription is pretty expensive.

Me: That's okay, I know it's not a generic and my co-pay will still be quite a bit.

Clerk: Okay, that will be $611.29

Me: OH MY GOSH!

Clerk: Yes, that's a lot for a 30-day supply (looking at bottle)...I mean a FIFTEEN DAY SUPPLY. It doesn't look like you have insurance is why it costs so much.

Me: Yes, I do have insurance and have received other prescriptions here. It needs to be ran through on my prescription insurance plan. Here's my insurance card.

Clerk: (After returning to me at the counter). Well, your insurance company says they won't cover this for you unless you are under age 17. Do you still want this prescription?

Me: Well $611.29 for 15 pills for this condition is a little over my limit. I'll figure something else out.

Woooooooooooowwwww. And, I had received this "trial prescription" from my primary care because I wanted to use Provigil instead of Nuvigil which is MORE EXPENSIVE!!!

So, now I need to talk sleep doc or primary care into prescribing for me Ritalin.

I have used Ritalin over the last few years while my OSA was undiagnosed. I have never had a problem with it or been hooked on it. I was prescribed 3 pills a day and only really ever took 1 a day.

And they are going to have to do something. I am the morning shift now where I'm at work at 5:30 a.m. and I'm starting to have a lot of daytime sleepiness because I'm not getting enough sleep at night.

And to make it a little worse -- last night I was watching the end of something I had taped. I think about 2 minutes into the show, I fell asleep WITHOUT my mask on.

It's the first time I have been without my cpap at night (other than the flu night, but that night I didn't sleep anyway -- too busy ......well you know).

Soooooooooooooooo I'm walking into walls again. Going to go to bed early tonight though which should help.

Soooooooooooooooo Plan B!!!!!

[brain_cloud]

If you haven't already, you might want to try the generic for Adderall XR. Generic and once per day dosing. Maybe Ritalin has one too.

[Muse-Inc]

...Clerk: (After returning to me at the counter). Well, your insurance company says they won't cover this for you unless you are under age 17...

Sounds like a script for an ADHD drug and not one for adult daytime sleepiness (EDS)

[elena88]

thats incredible!
I have a similar story..

My sleep doctor ordered something for me, but since Im so sensitive, she ordred it in half the normal does.. five mg instead of ten..
so we go to the store to pick it up and its five hundred dollars! of course i refuse the prescription... and I say.. dont you have
anything LIKE this which is less expensive?

And she says, well yes we do, we have THE EXACT same thing in ten mg..

Me: how much is that?

her: five dollars..

me : five dollars a pill????

her: no five dollars for a thirty day supply, the five mg if five hundred dollars..

WTF?

Well I will get the ten, and cut them in half..

Her: Well they figured you would do that so they put it in capsule form!

ME: can I just buy two of the five mg pills, meds never work for me anyway..

Her: sure you can, a lot of people are buying buy the pill now..

me: why is half the dosage one hundred times more?

Because the drug companies are issueing notices to the doctors that they have a brand new lower dosage available!

[physicsbob]

My doctor had to apply to the insurance company for a authorization for me to get them to pay for my Concerta (time release Ritilan) you could go that route. Or have your doctor look into prescribing Modafinil which is the generic of Provigil. Cephalon, the company that makes it is trying to play games and say it is still under patient when it expired in 2006 and is trying to prevent the generic on the market.

Bob

[Laurie1041]

As the OP suggested, ask your doc to (actually a staff member does this) get a "prior authorization" from your insurance company for the medication that was prescribed. Most prior authorizations are approved. The people who lose out are those who get the bad news at the pharmacy and tell their doctor that their Rx is not covered. Many docs will not offer to get the "prior auth" from your insurance company because it is a paperwork shuffle. You can call your doctor's office and ask to speak to his "nurse".
You can also go to your pharmacy benefits online and find out what is required for the prior auth. This may not be the only time that you need to go through this process so you might as well become familiar with it. I hope this helps. Laurie

[jonquiljo]

As the OP suggested, ask your doc to (actually a staff member does this) get a "prior authorization" from your insurance company for the medication that was prescribed. Most prior authorizations are approved. The people who lose out are those who get the bad news at the pharmacy and tell their doctor that their Rx is not covered. Many docs will not offer to get the "prior auth" from your insurance company because it is a paperwork shuffle.

Good suggestion. I will add one more thing. If you are on a PPO plan and Provigil has been FDA approved for OSA, then you should be able to get prior authorization approved. It sounds to me as if your PCP had already filed for prior authorization under the diagnosis of ADHD (why under 17 - unless it was that). PCP's aren't too swift when it comes to doing this - so you've got to keep after them. If Provigalil is FDA approved for OSA - then make them file a prior authorization with an OSA diagnosis. It may seem "duh" to you and I, but many Dr' are that "duh!").

Now if you have HMO coverage, don't hold your breath (pun intended). Also, if you are PPO and Provigil has been approved for OSA, then you can file a grievance with your state insurance board. Most states have them and (at least in California) they go over it fairly quickly. If you are in the right - the insurer must pay for the meds. The state forces them to. Lots of insurance companies play the game of denying you so that you need to appeal. This eliminates 90% of the people who want it off the bat - as they aren't going to fill out the form (or think their insurer will get back at them - they can't, they won't, they don't). You need to generally do this only once and you are fine.

I fought for a year to get my wife coverage of a pain medication that was totally legitimate and warranted in her case, but that the insurance company did not want to pay for (it was pricey). Her Dr. filled out authorization after authorization and got nowhere - and he is a pain specialist. I finally filed a grievance with the California state board and we won - she is covered until 2099! I am saying all this because it saves us $3000 a month in drugs we were paying for out of pocket when they should have been insured. Never say never.

Frankly I think the suggestion for Adderall XR earlier in the thread is the best. It's available generic these days and its not going to cost you much if you don't get it covered too. But Adult ADD is a bona-fide condition (I have it) and the insurers are required to give you these things if the diagnosis is the correct one. Frankly, I'd try the sleep Dr. He or she may not Rx as may prescriptions for these meds, but they probably know better than a PCP how to get them through an insurance company.

Good luck, and if you need any info - feel free to PM me - I am a old hand at kicking back at insurance companies and getting what you deserve.