Matt: one other thing - if you are F4? why did you even have to appeal?  Who did you end up getting the drug from? Your insurance or Gilead? not that it matters, just curious. Also what state are u in?

 Wow 24 pgs? You got me beat!  You must be like me: even tho you know they will probably deny again you somewhat enjoy the challenge of submitting a good appeal. I could have shot one out in 15 min, one page long and had the same result but I didn't want CDPHP to think they were pulling one over on me. I wanted them to know I knew exactly what was going on & deny me or not they weren't fooling me.

We can spend a lot of time being pissed at the insurance companies for saying no and for the pharma's for pricing drugs so outrageously high. But at the end of the day the reality is that: if most ins companies did give a $100k drug to every single member who needed it they very well might go bankrupt.  (my doctor said they had 300 patients denied - altho I find that hard to believe that's only 1 doctor in one town; do the math!! $30 million)  Where to place blame for these astronomical costs for the drugs?  Did the developers & CEO's demand outrageous salaries? Is the government to blame for costs of R&D licensing or Liability costs?  From a business perspective you have to make back your costs and of course you want to earn a profit at some point; preferably sooner than later.  Just think how much research and analysis Gilead had to do just to figure out how much it would cost them in lost profits to give the drug for free. How many people have HepC, how many didn't meet the "guideline" requirements to get covered, of those how many were under $100k household income & of those, how many would actually apply? Right about now most people are on their 2nd denial process - although Gilead says no, I have to wonder if there is a point where they would have to shut the offer down. Will they lower their price?  You know they aren't even giving ins companies the typical 20% discount!  Then too, how can they offer it for $800-900 in a 3rd world country but not offer it for a reasonable price to its own citizens.  To me that is the real outrage!

I guess at the end of the day this dilemma may never change and all we can do is stay educated and proactive and if someone puts up a barricade we knock it down or go around and we don't stop until we get what we need to be healthy. If you are so inclined, speak out - tell your story - you know HepC is at least in the news right now. You certainly never saw ads in magazines or commercials on tv a year ago!  

Anyway, didn't mean to get on that tangent but when you've seen for yourself what the healthcare system is really like you can't help but wish you could do something change things.  I guess that's why I post my experience and how to just get out there and get the drug you need to be healthy.  It's something.

Hey BJ

Thanks for writing out all the proper data and procedure for others that may go through a similar task. Nice complete job.

You are correct in that some doctors will do very little to help with writing a appeal for us, my experience was like yours hardly any help at all. I had to beg him to write a letter of medical necessity so I could include it with my 24 page appeal, and thats all he contributed.

matt  

Thanks so much BJ!!!  I see what I'll be doing this weekend...I truly appreciate all the help!

sounds basically what mine said too. Ask your NP about how long it will be. If she's backlogged more than 2 weeks I'd look into your insurance and see if you can do the appeal yourself. I think you can with most, if not all. Then just have her write a letter to support why you need it sooner vs later. Look at your insurance and see if they have any required stuff in an appeal.  Otherwise you can go online and look at samples & things to say.

here are a few sites I used:

Patient Advocate Site:  http://www.patientadvocate.org/help.php

Info on the Appeals Process:  http://www.patientadvocate.org/requests/publications/Guide-Appeals-Process.pdf
                                                http://obamacarefacts.com/appeal-health-insurance-denial/

Reasons they use to Deny:  http://www.carcinoid.org/content/excerpt-19-not-medically-necessary-use-their-weapons

Sample Letter:   https://www.leememorial.org/businessoffice/PDF/Sample-Letter.pdf

Reasons for Early Treatment: (Very Good Info)  http://www.natap.org/2014/HCV/080814_02.htm

NYS - Where to Lodge Complaints AGainst Your Ins Provider:  https://www.health.ny.gov/health_care/managed_care/complaints/

Hey BJ, here's what it says:

This letter is to inform you that United HealthCare Services on behalf of Oxford is unable to approve your physician's request for coverage of Harvoni.  The request did not meet the conditions necessary for coverage for the following reasons:
1.  Submission of medical records documenting advanced fibrosis
2.  You have failed or cannot use Sovaldi.

"This determination........that the requested coverage is not medically necessary under NYS Law for the purposes of your appeal rights."

I don't have advanced fibrosis, and I'm treatment naive.  And yes, the NP is doing an appeal, along with all the other denials from other patients they received.  But she is not hopeful.  They told me this Dec. 23rd which was my last visit, that they are getting denials left and right with many insurance plans, not only mine.  But they submitted the request for Harvoni anyways for me Jan. 5th.  I'm assuming the appeal won't be granted if she's telling me to get started with Support Path.  

I'm glad I have someone to contact who just went through this process.  Thanks BJ for posting all this..

definitely ask me anything. So  your NP is doing the appeal? wow!  I had to do mine by myself. You can do the same too if she is so swamped that the process starts to take to  long.  If you don't mind, what "reasons" did they use?  did they us the "not medically necessary" or quote the AASLD guidelines saying  you aren't "sick enough"?  If they are using that crap then you'll probably just get denied again.  Especially, like I said earlier if they have a history of denying all except the sickest.  If that is the case the sooner you get that denial letter the faster you can go to Support Path. 

BJ, You are amazing!!!  I got my official denial today in the mail and emailed my NP to ask if she needs this for the appeal and she replied: "Just hold on to it, have not written appeal letter yet.  Feel free to start with support path for assistance - Mysupportpath.com".

And I think to myself, okay, great, where do I begin, what do I say, how do I start -- that's not really much help she gave me here.  Come here to vent and low and behold see your post.  Thank you so much!

I'll print your post out and get started..Any questions, I know where to go.  

THANK YOU!

BJ,

I'm giving you an A+ for doing such a thorough job.  This info will be a big help to others going through the denial/appeal process.

Hey BJ,

All I can say is WOW and thank you for your helpful and instructional post!! I wish you the best of luck. Looks like you're handling things very well. Sad that your doctor wasn't the help he swore to be. Hopefully your hard work hasn't gone unnoticed by him. Good luck!

Tig

thank you for all the support and kind words. 

For anyone who is finding themselves in the same boat as I - I would venture to say if you got denied once = you will again. And, altho I expected otherwise, my doctor hardly helped me at all with my appeal. Said "it wasn't worth his time" since I would be denied anyway.  However, you must go thru the appeal process & have that 2nd denial to ask Gilead for help obtaining the drug.  In the end he did write a brief letter as to why I needed to start treatment as soon as possible but it wasn't much.  Even tho I was 99.99% sure CDPHP would deny me again I couldn't help but try to present the best appeal possible.  I looked up all sorts of stuff on the internet; learned what their causes for denial meant and how to respond to them, even found some studies to support getting everyone treated regarding of liver status etc.  It was 7 pgs long by the time I was done.  In the end they just used the same lame excuses as they did the first time. That it was not "medically necessary" and that per the AASLD "the sickest should be treated first.....".                  The denial letter was dated after the AASLD came out w/ their updated guidelines in December but it seemed they didn't bother to read them.  

Insurance companies have 30 days to respond. 3 days for expedited appeals.  I tried that but knew I wouldn't qualify! But I figured what the heck....

While you are waiting start getting your stuff together & call Gilead and get registered.  Let them know you are waiting for your appeal to be decided. This will help expedite things later on.

Once I got the 2nd denial I was able to go to the "support path" for help.Everyone is very friendly and helpful.  They answered all my questions and instructed me on what to do next:

First I went online & opened the "Intake Form" (it's in a fill-able pdf format you can save on your computer) Here is the link to the form, NOT the website:
http://www.mysupportpath.com/Gilead-SOF/documents/Support_Path_Intake_Form.pdf

Put together the package as required.   You can snail mail or fax (no email)  If you use USPS send either via Priority mail so you have tracking & can prove it was delivered or Registered with a Signature Proof of Delivery.  I faxed mine using an online fax site (http://faxzero.com/) - since it was 21 pages long I did have to pay but it only cost $2.  The package must include the following & make copies for yourself!!

Here's what you need: 

- Cover Letter - Include a bried description of your current situation, note your health status, if you are off work due to side effects etc, how HepC has affected your life.  Keep it brief but an overview of your personal situation

- Intake Form.- print this off the Support Path Website.  Most of it you must complete, but page #1 is for your Dr to complete.  It is a fillable form so you can key all the info you know onto it, save it and print it out.  I competed everything I knew then physically went by my Drs office for him to complete, date & sign.   I told them I would be coming by and would wait.  All he has to fill out is the dosage info, his tax ID & license etc.  You can also email or fax it to them then go pick up.  In any case he does page #1, you do 2-4.  Make sure you fill out everything - even the repeated info in the upper corner of each page!! DO NOT leave anything required off or it will hold things up. This form is 4 pgs long

- Copy of your insurance card, both sides.  If not insured you must complete the section

- Proof of income - 2 pay stubs, etc.  If you are not employed you will have to respond accordingly

- Proof of citizenship - I used my NYS driver lic & a bank stmt (you can also use a utility bill)

- Copy of your Drs original "Pre-Authorization" request to your insurance company (pick up the same time you have him sign the Intake Form or have them mail, email, fax to you)

- Copy of your Ins Co #1 Denial 

- any Letters from your Drs supporting why you should treat

-  Copy of your Ins Co #2 Denial (I didn't send my Appeal - not necessary)

***Faxing - What I did, and it did take more time but made things much easier in the end: Save all forms & documents as a pdf files.  My printer has a scanner so I scanned the copies of my packette into my computer & saved as pdf files; all in one folder.  That way, when I faxed, I could just go down the line and attach all the documents & send off to Gilead. Even save your cover letter which is probably a word doc as a  pdf. That way all the stuff you fax is in the same format - just makes it easier. 

If you figure you will go this route start getting this stuff together now.  I expected that it would be at least 30 days before  heard anything from Gilead. They are swamped right now as people get their 2nd denials.  However, proof that taking the time to be thourough pays off: they responded to me in 7 days!! That is like so unheard of - the rep said that is the fastest anyone he knows of got approved! 

Once they approve you they fax a form over for your Dr to complete.  Basically a script - your treatment plan. Your Dr then faxes back to Gilead.  My Dr did mine the same day.  Call & let your doctor know it's on the way & follow to make sure they got it and the importance of getting right back to Gilead.  Also follow up with Gilead to be sure they got it. If yes, go over it and make sure the treatment plan is the same you are expecting as previously discussed w/your doc. (you never know so better to confirm now then have an issue later on)

Once Gilead gets the form back they forward to their pharmacy, Covace.  Typically they will call you to confirm shipping info & let you know when you will receive it.  Someone has to be home to sign for it.  I just so happened to call today to verify they got my doctors form back OK and while on the phone, the Gilead rep called Covace and set everything up for me.  I should have my Harvoni on Thursday (usually 3 days but we have the weekend & Mon is a holiday)   

If there is anything I can do to help or if anyone has any questions please don't hesitate to ask or private email me.  

(someone asked: I am on 12 weeks - I had previously tried both the old interferon/riba treatment & Telaprevir/Riba - had to stop both under a month I had such a bad reaction to the interferon & Ribavirin)

If you want to get treatment don't hesitate to do so. But we have to be proactive. Don't expect anyone to do all this for you or keep on top of things.  Chances are if you got denied once you will again so get started on the process.  Get your appeal in & spend only as much time on it as you have chance for approval.  You never know but let's face it the cards are stacked against us right now. You can ask your Drs how many patients he has & how many are getting approved by the same insurance as you.  If you know that they are turning people down who are not in advanced liver disease then just get right on this and get to Gilead for help.  Absolutely NO reason to wait if it's your choice to treat now.

Good Luck Folks! Now I am anxious to read about people already taking Harvoni, what it 's really like etc. 

If I can be of any help let me know...

 good to hear :) for i may headed down the same road ...

this post gives me forsight into things to come.....

 harvoni ..laser guided bomb... or 12 gauge shotgun VieKira

Hey BJ

Congrats on getting on the Harvoni Train, you should never feel any misgiving on receiving treatment via the Support Path. Gilead is making a enormous profit on this product so it can well afford to offer this program to many many people.

Are you going 12 weeks or 24 months?

matt  

Hi BJ, I'm so happy to hear this good news. God bless Gilead. Is that blasphemy? Ah well,...

If all else fails, there is always Gilead. Seriously, I'm glad it has worked out for you and I hope it is an easy trip for you. Take care.

Hi BJ, the perseverance has paid off.  Excited and happy for you.  Quite certain all here are overjoyed you getting these meds.  It's sometimes difficult to jump through all the hoops.  Glad you're getting started.....onward to SVR!  :)

Hi BJ,

That is great news, you deserve it!  Good for you for jumping through all the hoops, you got the job done. I know this will be very encouraging to lots of people.

Hey BJ,

Congratulations!!!!! That's some very happy news and I'm thrilled for you! It won't be long now and you'll be chugging down the track via the Harvoni Train. All aboard!!! Good luck....

Tig

Hi BJ, just the post I needed to see...I was just advised my insurance company United Health Care in NY denied my prescription for Harvoni.  1st Denial.  The nurse practitioner said they are working on the appeal, along with all the others that were denied by various insurance companies..I was disappointed, but not shocked, about being denied.  But I was happy to read your post and will take note of what to do next if I get the 2nd denial.  Happy for you!!  Thanks for posting!

After being denied - twice by my insurance company, CDPHP in New York - I applied to Gilead's Support Path to see if I could obtain Harvoni thru them.  I completed the Intake form & attached all the documents they wanted: Proof of Citizenship (driver lic & Utility bill), Proof of income (2 pay cheks - income must be under $100,000 yr), My doctor's initial pre-auth for Harvoni to CDPHP, Denial #1, Dr letters supporting why I needed to get on treatment as soon as possible (I had these from 3 diff doctors), & denial #2.  I faxed all this over using an online fax for $1.99 (it was 20 pages long).  That was on Jan 7th.

Today I got a call that I was approved for Harvoni thru Gilead at no cost to me!!! 

I can't believe it - I mean I sort of knew I should qualify but you never know until you actually get the call. I'm just so shocked at how quickly I got approved.  Just supports why you should take the time to ensure you give them everything they need.  Makes their job very easy!! 

As we spoke they faxed my Dr a form to complete - basically a script. Once he faxes that back to them then they pass it along to their supplier. Next the supplier will call me to determine the best way to get the drug to me. Once that's done I guess it will be on it's way!! 

I am both nervous & excited.  Nervous because I am going to be putting this major drug into my system & I pray I don't get bad side effects because I really don't want to have to stop.  And excited because I want this freekin virus out of my body !! And most of all I want my energy back and be able to think clearly - get things done, get back to hiking and enjoying life!

So if anyone is having difficulty with their insurance just let them deny twice and go to Gilead. For once things went as planned - heck, even better!

Lastly:  I just hope -  REALLY HOPE that people won't think badly of me for going after this drug. We don't know each other's circumstances or have to live in each other's shoes -  this is a very personal decision.

And, I want to make it clear that I want EVERYONE to receive treatment for HepC and the sooner the better!!