This will be redundant to many...but important to the newer folks.

Zomig NS is my "last resort" savior...effective 99% of the time after O2 and energy drinks have failed. Thankfully rare these days...but vital to my peace of mind. IOW...better to have and not need than vice versa....

My company recently changed health insurance provider. They reviewed my scripts and sent me a pointed letter stating they would NOT cover my script for Zomig NS (HEY, I hadn't even tried to refill). Been there...done that... with the last 3 providers. Used to frustrate and piss me off...until I learned how to play the game.

1) Don't mess with arguing with them directly....unless you have no choice. Contact the broker who got them your company's business. They are indeed the insurance company customer...you are NOT...no matter how logical it seems that you are....and the broker can get results more efficiently. Don't despair if this is not your case, it's just a little bit harder.

2) Calmly and precisely explain why you AND your Dr have decided this is the med for you. Ask for the appeal process paperwork. Ask for their assistance.

3) In my case, that was an 8 page document...blathering on and on about how Zomig was NOT recognized as a first line abortive, not proven effective, not any better than sumatriptan/Imitrex...NOT, NOT, NOT....all backed by CAREFULLY selected references.

It's all CRAP...what they mean is it's not generic... therefore more expensive...and they hope you will be quiet and compliant and let THEM decide what is in your own best interest.

4) In that tome you will find the criteria that you must meet to be approved (two pages worth in my case).
Now then, because of who I am...and having learned the game....and wishing a little fun in this...I basically wrote the response myself. Answering every "denial possibility" with the reason why it was not valid....and the script I need IS. You will not need to do same IF you have  the physician/med center advocate you absolutely need....

5) CRITICAL...CRITICAL...CRITICAL....you have to find a treating provider that is willing to be that advocate. Keep trying if your current is not...it can be hard...life in pain and anguish is WORSE. In my case,  it is Swedish Pain and Headache Center, Seattle.

When I presented this case (and respectfully... my own thoughts on an appeal) last week, the treating PA smiled, nodded...and said...."don't worry, we know how to deal with this, it's a regular job, I'll write the appeal". Today I received a single page response from the insurance company. Script APPROVED...12 units a month...just like I asked for....

Don't give up, don't give in, don't despair...PLAY... THE... GAME! They want you to go away...DON'T...it really messes with 'em  :D

If you need help...come here...

Best,

Jon

Do you think that would work for scripts like Migranal, asking for more than the 8 doses/month? Glad you had success beating the system back a bit. Blessings. lance

Jon, thanks for such a clear, precise statement. We have so many who don't know how to represent/present themselves in these situations that they are left in frustrated anger and/or resignation.

I got rejected this morning.... how strange...

My doc said she will call the insurance co... so thats another thing to try

Wimsey... I heard Migranal is not in the same class so if its works just as well it might be an end around your insurance co policies..... I havent tried migranal yet.

wimsey1 wrote on Apr 29^th, 2011 at 8:19am:

Do you think that would work for scripts like Migranal, asking for more than the 8 doses/month? Glad you had success beating the system back a bit. Blessings. lance

Lance...I don't see why not. Bear in mind that since there are no specific meds for ch...and they don't "get" ch...the ins companies immediately think "migraine". I nearly blew a gasket when I first heard..."you CAN'T be having that many migraines". DUH...it AINT migraine...your limits are meaningless to my condition....and that's when the fight started.....

See my response to Josh.

Best,

Jon

This, may or may not help also Jon.

        START PRINTPAGEMultimedia File Viewing and Clickable Links are available for Registered Members only!!  You need to or END PRINTPAGE

[quote author=7B5E595356687F5840525B5B370 link=1304035440/5#5 date=1304120020]This, may or may not help also Jon.

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OH...ABSOLUTELY Linda....good stuff. I claim NO expertise in anything but "fish smelling"....and I simply...to quote Issac Newton..."stand on the shoulders of giants" here at ch.com. I just wanted to share how I fought this screwed system...it can be done...successfully. I encourage anyone facing insurance denial to research the site...there's GOLD to be found.

The agony of this condition has frustrated me for a long time...and my brothers and sisters suffering JUST... PISSES.... ME... OFF!  Until the medical/insurance community truly understands...I consider it my responsibility..as part of this family... to share what has worked for this one clusterhead ...hoping it will help another...or two....or......

My pc locked up in responding to Josh...was almost done...has got me verklempt...but I'll get over it...

Best,

Jon

yea..

Im going to have a go at it on monday but luckily Im a taper of prednisone right now so Im good for a little...

is anyone here really familiar with prednisone I have a few questions about it.....?