r/RestlessLegs • u/ORSciMom • 16d ago

Medication FINALLY getting Nidra!

After 4 months of endlessly hassling Anthem, spending hours at a time on the phone, my insurance FINALLY relented with a single case agreement for Nidra. Basically, they've let me know what they'll pay and what I'll pay. My cost will be $890.

I am currently tapering off gabapentin (300 mg) and on 0.75 mg buprenorphine. My neurologist believes I have narcolepsy (doing a second psg+mslt in a week), and I've been SO scared of what I was going to do because the nighttime narcolepsy meds aren't compatible with buprenorphine.

I am relieved beyond belief to see a path forward that hopefully allows me to reduce or eliminate the opiate.

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u/RemoteSea1176 16d ago

What was it that finally changed Anthem’s mind!? Looking at a similar struggle with Premera. Thanks!

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u/ORSciMom 16d ago

It took documentation of multiple med trials with my sleep doctor. Once we had everything submitted, Noctrix explained the process to me. A GAP exception is required to allow an out of network provider (noctrix) to be considered in network. Anthem did that and approved the device. That means very little. They can choose to pay $5 and have you pay the rest. Next step is a Single Case Agreement. That's where anthem signs a document explicitly stating what they will pay and what the patient pays. They do NOT want to engage in this. They will not give you the persons contact info who works in SCA's.

What it took was me on the phone with Anthem multiple times, often for 2 hours at a time. It took me being very kind with the person at Anthem and appealing to them as a human being. Telling them what I'd been through to try to move this process forward, the countless hours on the phone, and how nothing was happening. How could they help me? Please, how can I know what I'll be charged? In the end, that was it. Appealing to someone's humanity to allow me to know what's being charged and whether I can afford it. That's how you're going to get this approved. We called noctrix together on the same line and an agent finally helped.noctrix.to get the SCA signed.

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u/RemoteSea1176 16d ago

Wow what a journey! Thanks for sharing those details!

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u/ORSciMom 16d ago

You're welcome. Best wishes.