Hep C Discussion Forum

Gator Man · Senior Member

My Prescriptions Are on the way (almost)

Tig · Admin

This is getting more interesting, yet nauseating all the time. I find there seems to be a common denominator in all of the stories here and mine. That would be "Blue Cross/Blue Shield". I had a Florida plan with them when I started tx last May and it was approved for the duration, yet my specialty pharmacy had to reconfirm each and every prescription, monthly. So far, so good. But when our government decided to get involved in our healthcare system things started to go awry. I received a letter in November informing me, like so many others, that as of Dec. 31st my policy would be cancelled. They also informed me that my current pharmacy coverage would no longer be honored, "PERIOD". The decision had been made to end treatment at week 28 instead of 48. Had it been necessary to extend the treatment out to 48 weeks, which had been discussed, I wouldn't have been able to afford it. Like you Gator Man, had the need been there, they would've had one hell of a fight on their hands. I'll be watching to see if this is something BCBS is doing arbitrarily. They are responsible for many, many problems I'm experiencing right now. They are now in the process of reviewing previously approved lab tests to see if payment was warranted! This story is far from over I'm afraid. Good luck gents, keep up the fight!

Tig

OldenSlow · Senior Member

Dragon Slayer,

Distressing news. I will indeed be staying tuned, being 6 days out from ordering month #3, myself. I should be talking with my treatment director tomorrow and will see if she has any info/advice on the alarming trend. This ain't right. Best of luck your way...

p.s. Gator Man... Any news on your front?

Matt Chris · Guru

Hey Dragon Slayer

Strange brew indeed, sounds like the left hand is not talking to the right hand.

Maybe someone is making bad decisions from pressures from upper management without checking the medical side first, really stupid people making rash decisions.

Sounds like they rule in your favor if the Doctor is convincing enough.

matt

Hep-C Dragon Slayer · Veteran Member

Well it seems to be happening to a lot of us. My third month of Olysio was rejected. The Sovaldi and Riba were approved for month 3 but not the Olysio.

So my Specialty Pharmacy in FL is all over this. It seems that the insurance company (Community Blue) is stating that the Cosmos trials were never completed and that they only have 56 days of trial evidence to approve the drugs.

So I asked them how they could approve two months of a three month prescription and wait until I have 9 pills left to reject. I also let them know that I would seek legal council should I not stay UND and or become SVR. I told them I based my decision on seeking legal help for the fact that they approved a 90 day prescription upfront and on day 47 rejected the last 28 days of the drug based on clinical trial data ? This decision should have been made up front not in the middle of a tx plan. I am sure that my doctor would have held off the tx until all was approved if we knew this upfront.

Three hours later a manager from Community Blue called me and said they needed my doctor to send in my base and TX blood test results, they want a written statement on why I need the combo tx the determination as to how the combo was decided on and what the potential outcome would be if not continued.

My doctor contacted a doctor on the board of her gastro practice who is also involved in some level of authority with the AASLD and Highmark.

Last I heard this evening was that a conference call is planned for Friday afternoon to review the decision.

Tomorrow after I eat breakfast, I will be down to 8 Olysio pills,

Stay Tuned......

Gator Man · Senior Member

Tig56 wrote:
Gator Man,

That sucks! Get your doctor involved immediately and call both Sovaldi and Olysio' patient assistance programs tomorrow or even tonight and tell them what has happened. If you used a specialty pharmacy, call their insurance advocate right away. You can also contact your state insurance commissioner's office first thing and tell them. This is an outrageous example of abuse and I'd even contact an attorney if they leave you hanging with no choice but to stop Tx. Don't take no for an answer! If I can be of assistance at all, just say the word. This is ridiculous and with after the mess that has been made of our healthcare system, I'm not the least bit surprised. Hang in there, the fight has just begun!!!

Tig, I agree that it sucks! There is a two level expedited appeal process that the doctor's office is engaged in now. Evidently, this has happened before with some of their patients. I actually started out with a local specialty pharmacy that my doctor has worked with over the years. Unfortunately, my plan requires that I use CVS/Caremark that created the problems that I referenced regarding my first renewal.
I am definitely not taking no for an answer and unless they immediately reverse their decision, the fight has just begun. You have several good ideas in your post and will start with contacting the respective patient assistance programs and then on to the insurance commissioner's office. I told the doctors office that Anthem has one day to respond to an appeal at each level and that I need an answer by Thursday to consider my alternatives. It just happens that I am an attorney, although I don't practice in the area of health insurance law. I have talked to a few of my colleagues and would not hesitate to engage in litigation if I cannot reach an immediate resolution
I appreciate your offer of assistance and will give you the word if necessary. Your ideas already give me a good place to start and I will post any news regarding Anthem's denial upon receipt.
I had a premonition that there might be problems with insurance coverage, so I will urge everyone again to stay on top of your doctor, insurance company and pharmacy on getting refills. I still have a little time before I run out of meds solely because I heeded my own advice (my wife would remind me that is not usually the case).
P.S. Just got off the phone with the specialty pharmacy that handled the first prescription when CVS/Caremark had no Sovaldi or Olysio in stock. They have dealt with this problem before with Anthem and are sending a letter today that in the end threatens litigation if this matter is not promptly resolved. Apparently, this has worked in the past.

-- Edited by Gator Man on Tuesday 18th of February 2014 02:39:59 PM

-- Edited by Gator Man on Tuesday 18th of February 2014 02:43:45 PM

Tig · Admin

Gator Man,

That sucks! Get your doctor involved immediately and call both Sovaldi and Olysio' patient assistance programs tomorrow or even tonight and tell them what has happened. If you used a specialty pharmacy, call their insurance advocate right away. You can also contact your state insurance commissioner's office first thing and tell them. This is an outrageous example of abuse and I'd even contact an attorney if they leave you hanging with no choice but to stop Tx. Don't take no for an answer! If I can be of assistance at all, just say the word. This is ridiculous and with after the mess that has been made of our healthcare system, I'm not the least bit surprised. Hang in there, the fight has just begun!!!

Tig

OldenSlow · Senior Member

Ugh! Hate to hear that, Gator. Hoping things get smoothed out and tx can continue as planned. It's absurd to have been approved for a 12 week program and then cut off after 2 months. Something smells, here. I have to believe it's a bureaucratic glitch that will resolve in your favor. Certainly hope so, being an Anthem subscriber, myself. My meds are shopped out to OptumRx and things have sailed along well, so far. My final month's script is in their system and awaiting order, which I can't do before Feb. 26th. Keeping fingers crossed for both of us and everyone else.

Regards and best of luck,

Wayne

Gator Man · Senior Member

Gator Man wrote:
I'm glad I commenced on the refill "campaign" shortly after starting my first four weeks. The pharmacy provider even asked me when the last possible date they could deliver the meds. before my supply ran out. I would encourage anyone dealing with a big chain pharmacy to start early and be persistent. It took 4 or 5 phone calls to just get me registered in their system.

Since the prior post above, the 2nd refill of Sovaldi/Olysio has been denied by Anthem as being experimental. Why it would be more "experimental" than the first 2 months is anyone's guess? Of course this is being appealed, and I hope it helps that my doctor is a clinical provider for the COSMOS trial.
Insurance issues may create a new health problem for me, high blood pressure.

-- Edited by Gator Man on Monday 17th of February 2014 09:12:52 PM

Tig · Admin

Hi Lee,

I spoke with the pharmacy reps at the insurance companies I researched and got the same answer from all of them. Each plan first determines what each policy will cover. The policies are divided into different tiers of coverage (1-5 or Specialty). Low cost plans generally provide fewer options, most certainly medications. Every policy issued comes with it's own "Plan Formulary" or list of covered medications. As I mentioned, the low cost plans provide far fewer drug options and each has it's own separate tier system. What your plan considers a lower tier, mine considers a tier 4 or even classed as 5 - "specialty medication". They all told me the same thing and it should probably ring a bell with you too, "If you're unsure of your coverage, be sure to check the written information in your plan documentation, it is the deciding factor in all policies. Like we said earlier, get it in writing and if you talk to someone on the phone, do what I do, record it. Some states allow you to record a conversation without authorization from the other party. If you're in a state that requires you to notify the other party, do so and record the request and answer as you do it. I did that this month and it was the only thing that got my newest policy approved. They made a mistake and tried to blame me for it. My recording was enough to get the determination turned in my favor and I hope it got someone sat down and reminded to not blame the customer for their mistakes. There is less and less fairness in the business world and sometimes you have to do your best to stack the cards in your favor.

longld · Senior Member

According to a 2013 forecast from Express Scripts, specialty drugs are projected to increase 67% by the end of 2015, and 3 of the 4 costliest prescription therapy classes will be for specialty conditions.

Although specialty drugs account for a small percentage of total prescription claims volume their costs are rising at an alarming rate and are projected to exceed 50% or more of an employers pharmacy benefits spend in the next few years. The chart on the right indicates the anticipated annual changes in U.S. spending for the highest therapy classes of specialty pharmacy drugs through 2015.

Enavigo3891 · Senior Member

LTChaos wrote:
I received my first shipment today. I will likely start treatment on Sunday. They set me up for biweekly bloodwork, just a CBC, and I will not have a viral load test until the end of treatment.
It's surreal, This disease I have likely had for almost 30 years, will be gone so soon after I was diagnosed. I can't express how lucky I feel right now.
I have really wondered if I would have been better off knowing earlier, and I think the answer is no. Had I known before I had my children, I am not sure I would have decided to start a family. I sometimes wonder what different direction my life would have taken with that knowledge. Now I am not saying people should not be tested, imo everyone should be tested... But In my case, I think it worked out that I did not know.

I just told my doc the same thing today... I am 30 years old... I've had it for 30 years... it's pretty much been my identity - I found out when I was 13 but I've never been keen on what I heard about treatment. The knowledge of having it certainly directed many aspects of my life so I get what you mean. Well Good luck to you... I'll be following you on here since you'll be a few weeks ahead of me on the same journey!!

Tig · Admin

I agree with you Lee that a specialty pharmacy is a valuable asset while going through this treatment and any other critical care situation. However, with the changes in the new US healthcare system, be very careful and determine if you're covered. My previous insurance, the one that was cancelled because it was "substandard", covered all of my meds and they covered the services of the specialty pharmacy. My new "super duper" O-Care whiz bang approved policy states in no uncertain terms that the services of a specialty pharmacy are not authorized or covered. They also stated that these drugs fall under a Tier level that isn't covered by my new policy. If I would've had to treat for 48 weeks, I would've had to stop treatment for cost purposes. They warned me in advance, so at least I was aware of it. Many people aren't, so be sure and check. The doctors don't know and three quarters of the time the insurance rep on the phone doesn't know for sure. If you're approved for something and they decide after the fact that the approval was made in error, guess who's responsible for the payment? Be sure to confirm and double confirm, get it in writing, record the call, whatever you have to do to cover your butt! Until this new insurance dilemma is resolved, there's going to be change after change made to these policies. I ask people all the time, how do you like this "change" now?

longld · Senior Member

My speciality pharmacy is BriovaRx - I would recommend that anyone getting Sovaldi ONLY deal with a speciality pharmacy - they know what they are doing and do it quickly. My drugs will be here in 4 days from the time they initially called me. They understand all of the copay relief too!

globetrotter · Senior Member

It is fascinating reading how differently other countries deal with treatment and prescription options. In the UK the fabulous yet buckling health service that is the NHS whose ethos is 'free treatment for everyone at the point of entry' charge nothing for these treatments and deliver scripts straight to the pharmacy next door which I pick up every 4 weeks. Its not without its problems and there is a Postcode Lottery throughout the UK to the standards of treatment but my Trust have a top notch Hepatology Dept.

Sally

LTChaos · Veteran Member

I received my first shipment today. I will likely start treatment on Sunday. They set me up for biweekly bloodwork, just a CBC, and I will not have a viral load test until the end of treatment.

It's surreal, This disease I have likely had for almost 30 years, will be gone so soon after I was diagnosed. I can't express how lucky I feel right now.

I have really wondered if I would have been better off knowing earlier, and I think the answer is no. Had I known before I had my children, I am not sure I would have decided to start a family. I sometimes wonder what different direction my life would have taken with that knowledge. Now I am not saying people should not be tested, imo everyone should be tested... But In my case, I think it worked out that I did not know.

Tig · Admin

I also used the services of Bioplus Specialty Pharmacy in Florida. They are very prompt and quite knowledgeable about all aspects of our care. I had some questions one day and called their patient assist line. I spoke briefly with a nurse (RN) and then spoke with a pharmacist for over 15 minutes. She wouldn't hang up until all of my questions and concerns were answered. One other thing, they were very thorough when it came to insurance. They knew who to call, when to call and handled all of my claim/copay requests immediately over the phone. I never had a single problem with them. Good company!

Tig

Hep-C Dragon Slayer · Veteran Member

My doctor sent my triple tx prescription to a company in Florida named Bioplus Specialty Pharmacy, phone number Phone:(407) 830-8820.

They called me the day they got the order and in a 10 minute phone call set me up in their system. They processed the first months tx (28 days) and two business days later, they were FedX to my front door. They handle all the insurance paper work and all the coupons. I did have a copay for Riba and they processed that during this call.

I spent a total of 10 minutes on a call, which they called me.

On day 17 of the tx, they called me again and process the second months order. They also processed the co-pay coupons from Sovaldi. This time I was on the phone maybe 3 minutes. Two days later FedX delivered month two.

I assume the same protocol will happen for my third month.

What I learned is the local pharmacy (big chain) just does not handle specialty prescriptions of such nature all the time and Bioplus does. Their systems are set up for these types of transactions.

It was painless, I had nothing to do, no work or head aches.

I recommend them for prescription orders of this nature.

Gator Man · Senior Member

I had a local specialty pharmacy fill the first 28 day supply of Sovaldi/Olysio since the big chain pharmacy provider for my insurance plan didn't have them in their warehouse in December. Shortly after starting tx, the specialty pharmacy attempted to fill the next 28 day supply which was rejected by the pharmacy provider since they now had both drugs. Two weeks later and a dozen phone calls, I received both meds. yesterday. I had to deal with the coupons myself this go around.

The most troubling aspect of this ordeal was the the pharmacists calling me twice to "remind" me that these drugs are expensive, the insurance company could deny coverage post hoc and I would be responsible for the full $58k retail cost. They wanted to know if I had changed my mind regarding tx given the "possibility" that coverage "could" ultimately be denied.

I'm glad I commenced on the refill "campaign" shortly after starting my first four weeks. The pharmacy provider even asked me when the last possible date they could deliver the meds. before my supply ran out. I would encourage anyone dealing with a big chain pharmacy to start early and be persistent. It took 4 or 5 phone calls to just get me registered in their system.

-- Edited by Gator Man on Friday 24th of January 2014 03:05:56 PM

Matt Chris · Guru

Hey LTChaos

Congrats on getting your insurance company to go along with the meds.

Hoping all goes well

matt

Hep-C Dragon Slayer · Veteran Member

LTChaos,

Good news and congrats.

I agree with Tig56. My scripts for the Sovaldi, Olysio and Riba was filled by a specialty Pharmacy out of FL. They called me on day 17 and reordered from insurance. My second month is on its way for delivery tomorrow.

The special pharmacy also works out all the coupons details from the manufacture, I actually had no money out of pocket for my second month pills.

You will be on auto pilot once your doctor gets them the full 12 week script.

Tig · Admin

Congratulations! That's great news and I know it's a huge weight off your mind. I wouldn't worry about the monthly shipments, if that's what you end up having to do. I had to do that for 7 months and I dealt with a Specialty Pharmacy too. Once you have the initial approval and delivery, those pharmacy people know how to get the next one to you on time. I never had a problem. They called well in advance every month and delivered the meds right to my door. So try not to worry. That copay price is outstanding. Especially considering the Sovaldi costs $1000 per pill! I've already heard that insurance companies aren't approving more than 28 day supplies because the cost is so high and they are worried about people selling the drugs on the black market. That kind of behavior doesn't help anyone with the need of these medications. So you may experience some hesitation. They also like to see if you're going to respond to the meds with a 4 week viral test. If you're not responding, the medication can't be returned and someone sitting on 2 months supply that can't be used or returned gives the insurance geeks the chills!! So try not to worry about it, you'll be fine! Good luck!

Tig

LTChaos · Veteran Member

After wrestling a bit with my insurance company (BSNENY w Express Scripts), I believe my Sovaldi & Riba are on the way.

It did take a little coaxing & 3 weeks for it to finally go through. I think that was more due to the specialty pharmacy not understanding how to work with my insurance company. I had a call on Monday stating that the drugs were not part of my plan & would not be covered. I made 2 phone calls to the insurance company, was transferred several times & was finally told they were covered & the pharmacy needed to get prior authorization for coverage. I called the pharmacy back & they promised a call back in a few days.

Today I called the insurance company again, and they assured me the meds would be covered & quoted $100 co pay for Sovaldi & $60 for Ribaviran. I was ecstatic at that price! They were actually apologetic about the high copay. She said they have copay assistance if i needed it. The cost was for all 12 weeks, so I told her really, i could float that payment, I could hardly contain my relief!

On the way home from work 2 hours later, the original pharmacy called my cell & told me that everything was all set & they were ready to set up a shipment. With the coupons from the mfg, I will end up paying $15! The only problem I ran into is that my dr only wrote a script for 28 days. I questioned them & have to call the Dr tomorrow to see if I can get the full 12 weeks filled at once - from what my insurance company told me, I should only need to pay one co-pay for 90 days of treatment. I am not really concerned about the cost, but I do worry about having to wait for shipments of drugs every month (and potential insurance company delays).

So... hopefully I can start treatment by this time next week... Yay!

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