Insurance companies and pharmacy benefit managers have written policy/protocols for dispensing of specialty medications (Sovaldi/Olysio) and numerous others.  The criteria is spelled out.  In some instances the physician may get approval outside the standard protocol if there is a basis in "medical necessity."    Ask your insurance company for the written guidelines.  At least you will know the basis for the approval or denial.  Note these guidelines are routinely updated so you may want to check back from time to time.  If your medical condition and tx history falls within the written guidelines and you've been denied, by all means do a written appeal by certified mail.  They are obligated to pay if you meet the criteria.  If you don't meet the criteria you can advocate for yourself but the doc's request and supporting documentation is paramount.  Sometimes being treated by a teaching hospital hepatologist/transplant clinic is the key.  They deal with all the insurance companies and know what specifically is required to get approval.    Good luck, hope this works out. 

Fireman Rob wrote:

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Those "evil" drug companies are turning out to be not so evil. Without them, I wouldn't have any avenue to work through with my income level. 

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 LOL   They aren't so dumb.  First they take it away by making it cost prohibitive for the insurance companies.  Then they give it back and look like the heroes while the insurance companies become the villains.  

The truth is what they are giving back costs them maybe a couple hundred to manufacture.  They can afford to give some back and the PR they gain for being the good guys is priceless.

Trust me, the only ones who actually lose in this game are the patients/consumers--the average citizens--not all of them but many.    

I get my Rx through Express Scripts and ACC REdo ,  The insurance I have covered it. I have CIGNA,  Also in my case geno type 3 never had anything that would work even with the interferon so they can't say this Tx works use it.  So in my case there back were ageist the wall.

David,

I'm definitely going to change insurance companies during "Open Season" which isn't until November for me. I just hope I can change with this new discovered "pre-existing condition."

From the research I've done, this is an Express Scripts decision to force the drug companies to lower their prices. So any insurance tied to Express Scripts will likely be the same until prices drop from competition. Like you, it's going to be very trying to wait that long. I'm currently applying for assistance through Gilead's Support Path. I hope and pray they help me with Sovaldi. Janssen was really good to work with. 

Those "evil" drug companies are turning out to be not so evil. Without them, I wouldn't have any avenue to work through with my income level. I bet Blue across would be better as my experience really couldn't be any worse than UHC's wait for severe Cirrhosis Plan.

I'll keep you posted on my attempt to get Sovaldi through the drug company . 

I pray it works out!!  damn ins. companies..

Hey Rob , I'm about to start the same process I fear with UHC myself , kind of steeling up for it , but , what about switching insurance companies if it becomes an obvious dead end with UHC ? Any ideas on that ? I have a feeling this is fast becoming an industry-wide standard though ...

Fireman Rob wrote:

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I'm going through the same experience with UHC insurance. They have been a complete joke to work with and my Dr. said he's never had so many issues with an insurance company. I have had two appeals denied for Sovaldi alone and I'm still going nowhere fast with this process.

I've been trying to acquire meds since March. Hopefully you have better luck than I. United Health Care's insurance has been absolutely worthless to me. 

Good luck! -Rob

 

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Oh, Rob.  This makes me so angry!  You must have a doctor that is willing to fight, but even then, it can be an uphill battle that may or may not be won. I'm really hoping this situation improves (and I do think it will).   Arggg....

The denials from UHC have all said, "not medically necessary".  They also state that since I haven't tried interferon and riba first, they won't allow this new tx. It all comes down to money. What's really frustrating is I already have Olysio and they won't even cover the Sovaldi alone. I hope I'm not sounding too negative, I'm just over it. 

May one day we figure out a way to obtain tx. My Dr. Doesn't think Gileads new S/L will be any different through this company. Ugh...

Tig56 wrote:

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They sent me a notice telling me that my drugs would be considered a "specialty" medication on any replacement policy and not covered at all after the first of the year. 

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Aahh....the old "Specialty Drugs" trap.  This is what I was referring to in my May 7 post.  I would not be surprised to see more policies, that don't already contain this provision, to add it.

I ran into this myself back in 2011 when Incivek was just approved.  My policy only paid 50% of specialty drugs and incivek was considered a specialty drug. My policy also contained a 5K  out of pocket pharmaceutical cap.  What this meant was I had to pay 50% but only up to 5K.  I ended up paying 5K out of pocket. The worse news was I started my tx in November and my out of pocket cap started anew in Jan. so I had to pay 5K twice.  

I think there will be patient assistance programs who will help in these situations.  They may or may not be income based.   

People think Americans have easy access to the best of the best, and sometimes we do.  Other times it is just a constant battle that can take months or years to win, which in my personal opinion, only makes our health worse and, thus, increases healthcare costs.  

I'm going through the same experience with UHC insurance. They have been a complete joke to work with and my Dr. said he's never had so many issues with an insurance company. I have had two appeals denied for Sovaldi alone and I'm still going nowhere fast with this process.

I've been trying to acquire meds since March. Hopefully you have better luck than I. United Health Care's insurance has been absolutely worthless to me. 

Good luck! -Rob

Thanks guys ,

I do have a doctor who is firmly behind me getting this treatment approved and who is p*ssed off at the current state of affairs . I believe I contracted the virus in 2004  . My doc said the insurance company wants tests to verify no illicit toxins and /or alcohol in the system and that one needs to be at least stage 3 . So , tests next week (not a problem) and a fibroscan coming I guess . She adamantly believes in the medical necessity of treating less than stage 3 , and treating me , so , I'm good with her . 

Not so sure Im good with this insurance company . Or Gilead's pricing

Hi Jean and David,

I would recommend starting the appeal process too. Seems that more and more insurance carriers are denying the first application for Sovaldi and anything if the diagnosis doesn't indicate advanced fibrosis, F3 and above. The only way you're going to prove that is to submit biopsy or fibroscan documentation supporting it. Even if the appeals process extends out through the next best treatment opportunity, you should do it to get past any first appeal requirement. I had BCBS and wasn't sure if I was going to end treatment at week 28 or go out to 48. They sent me a notice telling me that my drugs would be considered a "specialty" medication on any replacement policy and not covered at all after the first of the year. I was on Interferon, Ribavirin and Victrelis. Fortunately I was able to to finish treatment before I had to deal with those issues. But whatever happened, I would've been required to go through a lengthy appeal  to fight their own narrow minded approval process. You will require a doctor that is firmly on your side and willing to go to bat for you. Some of these companies automatically deny a first time application when dealing with something this expensive, especially when there are other options available. When they receive an appeal, some of them will automatically approve it. It's a game with them, so a willingness to play along will often work in your favor. Good luck!

Tig

P.S.  David:  

Do get a fibroscan (or a liver biopsy if you can't get a fibroscan).  That is something your doctor should be encouraging no matter what, IMHO.  Just because you were only diagnosed 2 years ago doesn't mean the virus has only been in your body for 2 years.  

Hi David:

I have substantial liver disease but I am deeply concerned about insurance coverage for those who are F1-F-2.  I am hoping that as soon as the costs come down this will become a non-issue.  Costs will come down initially when the S/L combo is approved because Olysio (which is also incredibly expensive) will no longer be needed.  Costs will continue to decrease as more DAAs are approved which should begin shortly after S/L is approved and continue throughout 2015 and beyond.

Generally, I would recommend that people who have already been denied should go through the appeal process for a few reasons:  1) You may win,  2) If you win you will have potentially expedited the paperwork/approval process for the S/L combo should you decide to wait, and 3) Patient assistance programs may require that you have exhausted your appeals before they will kick in (you would have to check with the various patient assistance programs).

The problem with medical insurance appeals, and this is a significant problem, is that in order to win you must have a doctor supporting your appeal.  The insurance company is making a decision that is of a medical nature; that requires a medical expert to say the treatment is medically necessary.  If you don't have medical support you will not win. 

The answer to the question of whether to appeal or not will not be universal because everyone's situation is a little different and insurance policies and companies differ as well.

Hi Jean , everybody else ,                  I was just denied treatment as well , for Sovaldi/Riba , as I too am not sick enough for "them". We are just beginning the appeal process , and don't know what my fibrosis stage is at though my doctor seems sure it's not going to be stage 3 . I too have been waiting for non-interferon treatment , and was diagnosed two years ago . I'm still getting up to speed on a lot of things . And really disappointed . What are the new Gilead drugs coming this fall , Patiently Waiting ? , and even so , it'll still be a Sovaldi combo , which will still be really expensive , and my insurance company , UnitedHealthCare , would likely deny again because of price I would think . I'm wondering if I should try changing insurance companies , after this appeal attempt if it fails . Does anyone have any info on which companies out there are approving people with less than stage 3 fibrosis ? Guess that's two questions .


Thanks , David

-- Edited by david a on Sunday 25th of May 2014 04:52:55 PM

Thanks for your advice. I am appealing - going through a family member who has professional experience dealing with insurance appeals. But I'm prepared to wait. I just hope that people with more advanced disease than I have are getting their drugs approved by their insurance companies. 

Jean

Hi Jean:

It will be cheaper for the insurance companies to wait because the S/L combo will be less expensive than the S/O combo.  However, some insurance companies are likely to not want to pay for Sovaldi in any combo.  I expect they will try a number of approaches to avoid paying, including but not limited to, prioritizing patients (only F3-4) and classifying the new HepC drugs as "Specialty" drugs.  Many insurance companies only pay 50% for "specialty" drugs. In that case the patient would be responsible for the remaining 50% up to whatever their policy's pharmaceutical out-of-pocket cap is.  Gilead will pick up the tab for that 50% for many people.  They can afford to.  

Why not appeal?  If they approve then you already have a decision that they will pay for Sovaldi.  At that point you can decide whether to treat now or wait. If you decide to wait the decision they already made should expedite getting the approval for the S/L combo.  If they don't approve then you may have to appeal again.  By that time they may approve the S/L or you may have to keep fighting them unless patient assistance programs and/or Gilead will pay.  

Hang in there and take good care of your health in the meantime.  It will all work out but they won't make it easy.  Sovaldi won't lower their prices and insurance companies/government don't want to pay that much.  

Denied by insurance company (Blue Cross Blue Shield affiliate in Maine) for dual drug sofosbuvir and simeprevir - not sick enough - fibrosis only at stage 2 - threshold is stage 3. Doctor says slow progression, wait until fall and new drugs - looks like the guidelines from http://www.hcvguidelines.org.  Would much rather take an effective treatment and stop the further damage to my liver, but no choice. Should I appeal?

Thanks for advice,

Jean