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Hep C Discussion Forum -> On Treatment -> Insurance (Express Scripts) question...
Post Info TOPIC: Insurance (Express Scripts) question...
OldenSlow


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RE: Insurance (Express Scripts) question...
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Enavigo3891 wrote:

My advise is to stay on top of them and if you haven't already done so - make an online log-in on their website. I have gotten more accurate info about my prescriptions by logging in to my account on line than from any person I spoke with on the phone.

Ditto with OptumRx.  Creating an account allows one to view details of the transaction.  Total cost, amount paid by insurance, amount remaining pre-coupon, shipment tracking info, etc.



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66 y/o male - Geno 1b - F4 cirrhotic dx 2001 - 16 wk treatment w/ Sovaldi/Olysio/Riba - Und @ EOT+24 SVR

 
Tig


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I've also heard from various people that the insurance companies are very concerned that 1. the patient is responding appropriately to treatment before authorizing each 28 day Rx and 2. they are very concerned about fraud. Seems that Sovaldi is by weight and purpose, one of the most valuable commodities on the planet. The potential for fraud and theft is so high it scares them. There is no possibility (legally) to return the product once it has been delivered to the patient. I would like to see some sort of quantity guarantee once the Rx has been approved so there is no chance of a secondary denial. Call me overly cautious...

Tig



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Tig

68yo GT1A - 5 Mil - A2/F3 - (1996) Intron A - Non Responder, (2013) Peg/Riba/Vic SOT:05/23/13 EOT:12/04/13 SVR 9+ years!

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Enavigo3891


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Hey Zavr,

As Dragon Slayer mentioned - I'm an Express Scripts "victim" .. as is LT Chaos - she has also posted in the same post "my prescriptions are on the way... almost" about her trials and tribulations with Express Scripts.  Express Scripts has a mail order pharmacy where they do sent 90 days worth of prescriptions at once BUT from my experience that is only for legitimate maintenance medications like thyroid pills, birth control, etc - things you take 365 days a year. Express Scripts considers the HepC treatment meds "Specialty Drugs" and from my experience, LT's experience and everyone else's they are sending them out in 28 day supplies, not all at once. Think about it - the Sovaldi alone is $84k - that's a large risk to take by sending all 84 days at once.

Express scripts does place an expiration date on their approval - for example, my meds were approved 2/3/14 and my expiration is 4/28/14 which means I need to fill all meds by then. This is the reason i have cautioned another on this site who mentioned getting approved but then wanting to wait until June to start treatment - not sure that's possible with out a re-approval. If you read about my experience with Express Scripts as well as LT Chaos' in that other post, you will see that they are not the brightest individuals to deal with. I spent over 3 hours combined on the phone with the customer service line and the appeals line yesterday. I actually had a supervisor tell me she couldn't tell me the cost of my 3rd fill as it would require a coverage review and pre-auth (already done and I've already had 2 fills). My main issue with them was that my hospital has it's own Specialty Pharm who got the approval for both drugs and filled the first two (out of 3) fills and then I got a letter in the mail saying that I HAD TO move my Rx to their Specialty Pharm otherwise I would have to pay 100% on my third fill. They don't tell you this up front. LT Chaos had the same problem - she got the same exact letter in the mail and had to move her prescriptions mid treatment.

My advise is to stay on top of them and if you haven't already done so - make an online log-in on their website. I have gotten more accurate info about my prescriptions by logging in to my account on line than from any person I spoke with on the phone.



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Born HepC + in 1983 ... diagnosed @ age 13 ... GT2 ... 12 wks of Sovaldi/Riba from 2/11/14 to 5/5/14  #ribazombie

1/30/14 - Starting VL 1,922,967 * 3/11/14 - UND @ 4 wks * 7/29/14 - SVR12 * 11/6/14 - SVR24 * May 2015 - SVR52 * MAY 2016 - STILL UND * FEB 2018 - STILL UND

 
Hep-C Dragon Slayer


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Zavr,

 

See  Enavigo update in My prescription are almost on the way post.  It is about Express Scripts.  Seems that two of her refills are good one was not.



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GT 1A:  VL: 4,695,000, started treatment 1/6/13 with off label Sovaldi/Olysio/Riba     No Interferon due to Sarcoid  in liver and lungs.  Recent biopsy shows Cirrhosis level 5/6.  EOT 3/30/14. SVR 8 on 5/30/14
Hep-C Dragon Slayer


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Zavr, 

I do not have experience with Express scripts but I don't think I have heard any one getting more then 4 weeks at a time (which is 28 days not 30). 

From what I have learned the insurance company wants to make sure that the tx is responding before each refill and before they lay out $150,000 at one time.

With your tx of Sovaldi, Riba and Interferon, this is FDA approved in states and you should be fine for all 84 days.

 

Rybronco,  Same on your 28 versus 30 or 84 versus 90

You are taking same tx plan as me and others in the group.  This off label tx (Sovaldi / Olysio), for me was approved upfront as well but each 28 day refill had to get an authorization from insurance.

Our tx is not FDA approved and as you may have seen  in my post, you need to stay on top of your refills.  At day 14, call your pharmacy and have them go through the approval process and get them shipped.

 

Some off label members had to get doctors involved, or themselves to get the third refill.  I had several people involved as was denied the 3rd refill.

STAY ON TOP OF YOUR REFILLS

 

 



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GT 1A:  VL: 4,695,000, started treatment 1/6/13 with off label Sovaldi/Olysio/Riba     No Interferon due to Sarcoid  in liver and lungs.  Recent biopsy shows Cirrhosis level 5/6.  EOT 3/30/14. SVR 8 on 5/30/14
Rybronco


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First, awesome you were approved zavr.

I was approved through Express Scripts as well for the entire 90 day tx, I am receiving 30 day supplies of sov/oly at a time. I must call for refills one week prior to the end of the months supply.   I would guess it depends on the Plan you have as to whether or not they ship the entire course of therapy at once.  My plan is Aetna



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49 yo. G1a prior tx 2005 with peginf and RIBA 12 weeks dc due to side effects. vl 7.8mm Current tx Sovaldi/Olysio 12 weeks started 2-21-2014,  UND at 4 weeks, EOT+12 SVR
zavr


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Hi guys,

So, I just talked to Express Scripts, who, apparently, changed their minds and approved the Sovaldi+Ribavirin+INF treatment. The agent said that Sovaldi has been approved through end of May, and that it is a 90 day prescription (thus, all meds should mailed at once, not monthly).

If anyone has had experience with Express Scripts, do you know if it is truly possible that they mail all 12 weeks of Sovaldi together? That is, as long as I order the first fill by end of May, I will get all of my medication, without needing a second pre-authorization?

 

Thank you in advance for your help!

-zavr



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Gen 1b, 33yo. Started 12wk Viekira Pak on 2/28/2015. 

Baseline: VL=517K, AST=34, ALT=56. 

Wk4: VL=<15, AST=16, ALT=14.

Wk8: VL=UND, AST=17, ALT=14.

Wk12: VL=UND, Fibroscan: 3.4kPa, F0.

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