Patty Shafer, RN, MN
Epilepsy.com Resource Specialist
Access to seizure medicines is a critical problem for people worldwide, not just here in the United States. Many worry if they can get brand versus generic medicines, as they have had problems with switches between formulations, or can’t get access to some of the newer seizure medicines. The drugs may not be covered by insurance, or people may be charged an enormous amount for the medicine, or they don’t have any coverage for prescription medicine. The article reviewed by Dr. Sirven highlights that this is NOT a U.S problem, but one that affects people with epilepsy everywhere.
So what can be done? We often feel helpless and have to settle for what is available, even if it is not what the doctor or health care provider recommended. Some people may go without medication – a potentially life-threatening situation! Don’t let this happen and don’t take no for an answer!
There is not one answer for people, and where you live will affect options available to you. But if you are faced with problems obtaining seizure medicine or your choices or finances are limited, consider the following options. If you need help with any of this, ask a family member, friend, someone from your doctors’ office. Ideally, contact a social worker or resource specialist who has experience in connecting people with health care and financial resources. This may not be easy, but your health is worth the effort!
If you’re having trouble getting health insurance to cover seizure medicines:
- Look up the rules of your health plan - know what medicines are covered and if there are certain criteria or issues that may need to be addressed. For example, some plans may require documentation that a person can’t use a generic, that they have tried other seizure medicines, or why a certain amount is needed.
- Know how to request a prior authorization, called a PA. This is a form that requests approval from the insurance company to give you the medicine prescribed by your health care provider on the basis of medical necessity. Your health care provider will need to fill out a form or send a letter to your insurance plan with the name, dose and amount of medicine and why it is medically necessary for you. If there are limits to how many pills can be given at a time, called quantity limits, find out if your health care provider can give a different size tablet to equal the same daily amount of medicine you are supposed to take.
- If your doctor has filed a PA, make sure to follow up on this! Some times getting answers to the prior approval takes time. A phone call from you, the ‘patient’ can help speed things up.
- Don’t wait to the last minute to ask for a PA to be filed. Start this process early!
- If you are running out of medicine, tell the pharmacy that you have epilepsy and not taking medicines is very dangerous. You can have long or repeated seizures, called status epilepticus. An emergency supply of seizure medicine can be given to you.
- If you have run out of medicine, go to an emergency room, before you have a crisis! They can give an emergency supply of medicines and hopefully connect you with resources or other ways to obtain needed medicine.
- If your insurance company is not willing to cover the cost of the seizure medicine that your doctor has prescribed, file an appeal, ask for the cost of the seizure medicine at the lowest available cost, and ask your doctors and nurses to help you! Having letters from many people can help – try asking your legislator for help too!
Continue to Part 2: Affording the Cost of Medicines
by Patricia Osborne Shafer RN, MN
Resource Specialist, epilepsy.com
Last Reviewed: 7/11/2012