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Vomiting During Pregnancy--How to Get Diclegis Covered by Insurance

Updated on May 10, 2016

What Pregnancy Really Looks Like--A Pregnant Lady's View

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Nausea and Vomiting During Pregnancy

While most women suffer from nausea and vomiting during pregnancy (NVP) for only the first trimester of pregnancy, there are many women, like myself, who suffer from NVP during both the second and third trimesters of pregnancy.

Referring to NVP as “morning sickness” is utterly ridiculous. It is an all-day and all-night battle to keep your food down, a battle that is usually fought in vain.

At 25 weeks, my OB finally prescribed me a medication called Diclegis to treat vomiting during pregnancy, but when I went to the pharmacy to pick it up, I was informed my insurance had denied it indicating it wasn’t covered.

When I called my insurance, I was informed that before I could appeal the determination, the physician had to appeal it. My physician’s office appealed it, and a week later I was informed the appeal was denied. Surely if the doctor’s office couldn’t get it covered, I wouldn’t be able to…right? Wrong.

It took me five hours to get Diclegis approved by my insurance.

Not many people realize that if there is only one FDA-approved medication to treat a condition, even though it is a brand-name drug, an insurance company MUST pay for it. There are no ifs, ands or buts about it.

You will need to send an appeal letter to your insurance company. The first and most important issue you want to address is that Diclegis is the only FDA-approved medication to treat nausea and vomiting during pregnancy that poses no health risks to either mom or baby.

Continue with your appeal letter by listing your symptoms and how it impacts your quality of life (why it's medically necessary), and, if applicable, include your possible need to go to the emergency room for hydration. This will act as an incentive to your insurance to approve the medication. Insurance companies would much rather pay for medication than costly emergency room visit(s).

Template/Sample Appeal Letter

Name: Your Name

Date of Birth: Your date of birth

ID: Your member ID number

Claim#: Claim or Case number

This is a member appeal regarding the adverse benefit determination for the prescription drug Diclegis DR 10-10 mg tablet, a combination drug of B6 and an antihistamine.

Diclegis is the ONLY FDA-approved medication used to treat nausea and vomiting of pregnancy (NVP). FDA approval for this drug was issued on 04/08/2013. As of this date, there are no other medications approved for NVP which has proven to pose no risks for the health and safety of both mother and baby.

Although most women report an improvement with NVP after the first trimester, many women continue to experience NVP throughout the duration of their pregnancies. I am one of these women.

Currently I am ____ weeks pregnant. Since becoming pregnant, I have lost a total of ____ pounds. On an empty stomach, I am constantly gagging and retching. I throw up any type of small meal I attempt to eat. I throw up any type of beverage including ginger ale and water. Because of this, on several occasions I have contemplated going to the emergency room for hydration.

These symptoms have severely impacted my quality of life and often prevent me from leaving my home. It has caused extreme fatigue and exhaustion and also causes constant, chronic headaches and back pain.

Please reconsider coverage.

Sincerely,

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