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
If you need help...come here...
Best,
Jon
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Zomig nasal spray script....fighting ins denial (Read 1577 times)
