Thanks for posting the United Healthcare criteria. They quote the AASLD guidelines of "When & In Whom to Treat." I noticed both United Healthcare & Anthem/Express Scrips quote the AASLD guidelines but they only quote the part of the guidelines that suits their purposes. They set their criteria to treat only F3/F4/cirrhosis based on AASLD guidelines. But what they omit is that AASLD says F3/F4/cirrhosis should be treated FIRST. I think we can all agree on that. What bothers me is they omit the following information where AASLD says ALL patients with HCV should be treated. The insurance companies are really distorting the guidelines & it is important info to have if you need to file an appeal.
"Our recent addition to the Guidance prepared by a committee of leading liver experts from AASLD and The Infectious Diseases Society of America (IDSA) proposed that the sickest patients be treated first, but all patients who receive advice from their doctor to take newest medications should not be denied. The decision across the board should be in the hands of the clinician and the patient to make the decision. Unfortunately payers across America are denying treatment when a doctor has prescribed it for their patient. We adamantly disagree with this decision.
Our Guidance is not intended to be used by payers to deny access to treatment. In no way does this position contradict the evidence evaluated to produce the Guidance and the recommendation made in the Guidance to treat the sickest first, but recognizes need to treat all."
Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions (See Unique Patient Populations). Urgent initiation of treatment is recommended for some patients, such as those with advanced fibrosis or compensated cirrhosis (see Table 1).
Matt Chris said
Oct 30, 2014
Bravo for United Healthcare
At least they are using well respected Liver health organizations for there basis and resource to figured out acceptable criteria for the latest treatments.
This is in great contrast to the lame and outright ignorance of BCBS, they have no clue of whats happening with new treatments.
matt
Michaele said
Oct 30, 2014
Thanks Tig, the Part D I have says not covered, but with the right paperwork and the need to treat it can be had, well thats what I've been told. But it could take a long time, and appeals . Michaele
Tig said
Oct 30, 2014
It's good to see it written down, as it should be, but it's distressing to see the restrictions. Why shouldn't all eligible genotypes, viral loads, fibrosis stages and people with a treatment history, etc., etc., be eligible from the start? I think the best criteria for eligibility would be,
(1) Do you have HCV?
(2) Do you want to treat?
(3) Do you have a qualifying Genotype?
(4) Congratulations, you qualify!
Tig
@Michaele, yes that's the same company. However, they have multiple policies and that includes formularies as well.
Michaele said
Oct 30, 2014
Hi, at the risk of sounding stupid, is that the same UnitedHealthcare that AARP part D is insured through? Michaele
-- Edited by Michaele on Thursday 30th of October 2014 08:35:02 PM
-- Edited by Michaele on Thursday 30th of October 2014 08:35:22 PM
JLynch,
Thanks for posting the United Healthcare criteria. They quote the AASLD guidelines of "When & In Whom to Treat." I noticed both United Healthcare & Anthem/Express Scrips quote the AASLD guidelines but they only quote the part of the guidelines that suits their purposes. They set their criteria to treat only F3/F4/cirrhosis based on AASLD guidelines. But what they omit is that AASLD says F3/F4/cirrhosis should be treated FIRST. I think we can all agree on that. What bothers me is they omit the following information where AASLD says ALL patients with HCV should be treated. The insurance companies are really distorting the guidelines & it is important info to have if you need to file an appeal.
http://www.aasld.org/aboutus/publicpolicy/Pages/aasldhcvposition.aspx
"Our recent addition to the Guidance prepared by a committee of leading liver experts from AASLD and The Infectious Diseases Society of America (IDSA) proposed that the sickest patients be treated first, but all patients who receive advice from their doctor to take newest medications should not be denied. The decision across the board should be in the hands of the clinician and the patient to make the decision. Unfortunately payers across America are denying treatment when a doctor has prescribed it for their patient. We adamantly disagree with this decision.
Our Guidance is not intended to be used by payers to deny access to treatment. In no way does this position contradict the evidence evaluated to produce the Guidance and the recommendation made in the Guidance to treat the sickest first, but recognizes need to treat all."
AND
http://www.hcvguidelines.org/full-report/when-and-whom-initiate-hcv-therapy
Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions (See Unique Patient Populations). Urgent initiation of treatment is recommended for some patients, such as those with advanced fibrosis or compensated cirrhosis (see Table 1).
Bravo for United Healthcare
At least they are using well respected Liver health organizations for there basis and resource to figured out acceptable criteria for the latest treatments.
This is in great contrast to the lame and outright ignorance of BCBS, they have no clue of whats happening with new treatments.
matt
Thanks Tig, the Part D I have says not covered, but with the right paperwork and the need to treat it can be had, well thats what I've been told. But it could take a long time, and appeals . Michaele
It's good to see it written down, as it should be, but it's distressing to see the restrictions. Why shouldn't all eligible genotypes, viral loads, fibrosis stages and people with a treatment history, etc., etc., be eligible from the start? I think the best criteria for eligibility would be,
(1) Do you have HCV?
(2) Do you want to treat?
(3) Do you have a qualifying Genotype?
(4) Congratulations, you qualify!
Tig
@Michaele, yes that's the same company. However, they have multiple policies and that includes formularies as well.
Hi, at the risk of sounding stupid, is that the same UnitedHealthcare that AARP part D is insured through? Michaele
-- Edited by Michaele on Thursday 30th of October 2014 08:35:02 PM
-- Edited by Michaele on Thursday 30th of October 2014 08:35:22 PM
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Pharmacy%20Resources/Harvoni_Medical_Necessity.PDF