HIPAA, Blue Cross, and Cephalon

We know an older family of beagles, an Alpha stud and his Alpha mate. Clever dogs, the Alpha male is well employed and has medical insurance for his doggie family with Blue Cross of Alabama. His Alpha female has doggie narcolepsy which is covered . . . somedays.

Doggie narcolepsy is a life-long condition that came on when she was midway through her puppy-hood. It is the sleeping disorder which causes the victim to go to sleep, a cataplexy limper than a rag doll, almost instantly when triggered by extremely emotion including happiness.

The Alpha male, found this out when he took her out on his motorcycle and she would fall asleep on the back:

Fortunately, his motorcycle had a 'sissy bar' and feeling his female going limp, he would lean back and pin her to the sissy bar while slacking off on the throttle. He would reach a safe place on the shoulder and stay there until five or more minutes later, she would 'come too.' Then they could continue their trip and she only suffered a slight headache that soon went away. Regardless, clever dogs they loved each other and formed a pack.

Narcolepsy has been traced to missing brain cells that produce a peptide, hypocretin. The evidence suggests an auto-immune or infection kills off these specialized cells. But peptides are very 'sticky' and though hypocretin injected in the blood stream eliminates narcolepsy symptoms, within a couple of days, the effect is gone. Hypocretin replacement remains impractical unless stem cell research finds a way to repopulate these cells.

Today, treatment is for the symptoms include amphetamine class drugs, a non-amphetamine Provigil, and sleep medicine to improve REM patterns, another symptom used to diagnose narcolepsy. It is a life-long disorder but this posting is not about narcolepsy but the medical malpractice of Blue Cross and theivery of Cephalon who holds the Provigil patent.

Narcolepsy comes in different degrees and to 'stay normal', the Alpha female needs more Provigil than Blue Cross covers. When the Alpha dog challenged Blue Cross, they said they needed a 'peer reviewed paper' that supported the higher dosages the Alpha female needed. This was passed on to her sleep vet but he was unable to find a study that met the Blue Cross demand. Yet he had an Alpha female who without enough Provigil became listless and unable to fully function in the pack. Regardless, the Alpha male made enough and could use the canine 'flexible spending' account to make up the difference.

Two years ago, Blue Cross changed the rules and required 'pre-approval' for Provigil. The big dog found out when he went to fill the Provigil prescription only to be turned down at the doggie pharmacy. His Alpha female needed the medication to remain an active pack member so he had to pay full-price, no insurance coverage, for the expensive Provigil.

The Big dog wrote a letter to Blue Cross complaining that they did not notify any of the dogs who had been using Provigil for years. But Blue Cross claimed to have sent a notice to the kenel owners in San Diego. The local Huntsville dog keepers in the Canine Resource Department did not get a notice. Worse, the CIPPA law (Canine Information Pack Privacy Act) prevented the local keepers from even knowing which dogs needed this information. So the Big dog contacted the sleep vet and their office applied for and received permission for Provigil.

A year later, the Big dog went to get his mate's Provigil only to find the pre-approval had expired. Once again, he wrote a letter only this time to the Alabama Canine Insurance Office. He pointed out that narcolepsy is not a year-long, condition but a life-long condition. One pre-approval is OK but requiring an annual pre-approval increases the cost of the sleep vet and Blue Cross administration cost with no improvement in his mate's narcolepsy.

The Alabama Canine Insurance Office turned out to be a letter box for Blue Cross. They passed on the letter and received a reply that said,"It is our policy." They forwarded this letter to the Big dog and said, 'See they are saving money.' . . . The Big dog still growels.

Three months ago, the cost of the additional Provigil went up by $300. Surprised, the Big dog 'ate the cost' and cursed that he had not increased his flexible spending account more. When he discussed the price increase with his mate's sleep vet, he learned the Provigil salesman said,'Well our newest version is less expensive than Provigil.'

The patent on Provigil is (or has) run out but there is no generic, yet:

http://www.nytimes.com/2010/01/13/business/13generic.html?_r=1


Cephalon has made a minor change in Provigil and calls it Nuvigil. Yesterday, the doggie pharmacy reported the costs of the Alpha female dosage pill count is:

• $633.66 - 150 mg Nuvigil
• $703.51 - 250 mg Nuvigil (100 mg ~=$70 change in price)
• $1,100.00 - 200 mg Provigil

What confused the Alpha dog, briefly, was why 250 mg Nuvigil since Provigil comes in a 200 mg pill. One answer is the Nuvigil is less effective but another is the 250 mg Nuvigil will have 25% more active ingredient than a 200 mg generic. What this means is should a generic come available in 2012, the Nuvigil users getting a 200 mg pill will find it 'less effective.'

Currently, Blue Cross limits how much Provigil the Alpha female has covered each year. So the sleep vet will be asked to prescribe the pill dosage count of Provigil and we'll see if Blue Cross will cover the same quantities. The Big dog will work with the doggie pharmacy to see what can be done to repackage the Nuvigil in 200 mg doses.

The reason for this doggie tale is several humans are likely to run into the similar medical malpractices by their medical insurance company and drug company theivery. The lessons the Alpha dog wants to share with his human friends:

• Put the insurance company 'hot line' number on speed dial and before leaving the doctor's office, call and ask specificly about each prescription, the coverage and whether a pre-approval will be needed.
• Track your drug company before each renewal to see what 'press releases' they are announcing . . . track the patent expiration. Be prepared to deal with sudden, unannounced price changes.

Thanks,
Bob Wilson
An Alpha dog's best friend

 

No but my dentist noticed I'm 'grinding my teeth' and now I have this mouth piece to sleep with. Of course I might be grinding my teeth during the day.

Mostly I wanted to share the doggie tale with our friends who are facing major medical challenges. Even the famous have reported mothers having to fight the insurance companies as they were dieing of cancer.

Bob Wilson

 

Thanks,

I had ordered adrafinil and modafinil before they were licensed in the USA. We found them effective, modafinil more so than adrafinil which led to a side-effect of a headache. However, modafinil was expensive, $10/pill, and modafinil (aka., Provigil) was approved shortly thereafter for the same price. It was easier to use our insurance plan.

After the nuvigil test, the India supplier makes sense. If so, the one who holds the prescription, will make the order . . . no need to add a legal complication . . . clever beagles.

Bob Wilson