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Hep C Discussion Forum -> On Treatment -> Treatment Denied ) ;
Post Info TOPIC: Treatment Denied ) ;
Pericles


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Treatment Denied ) ;
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Rob,

From late December last year until March this year, I was in your shoes.  Blue Cross denied me coverage for off-label Sovaldi/Olysio/Ribavirin on the ground that it is "not medically necessary."  Then they denied two appeals as well.  The third appeal was the charm.  If I were you, I would definitely appeal, and if they deny you, appeal again, and again.

Best of luck.    



-- Edited by Pericles on Wednesday 16th of April 2014 03:34:36 AM



-- Edited by Pericles on Wednesday 16th of April 2014 07:41:08 AM

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Daniel138


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Keep fighting! I know Gilead is getting a lot of pressure from Congress and the World Health Organization to make Sovaldi more affordable. Just another example of big pharma putting profits before people. 



__________________

36 year old male, genotype 2a, no fibrosis, on 12 week Sovaldi/Ribavirin combo
Matt Chris


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Hey Rob

It might be a blessing that you will have to wait another 6 month or so. The Gilead combo is even a more powerful Hep C killer

Matt



__________________

"And in the end, the love you take is equal to the love you make"

61 year old Geno type A1, F4 Cirrhotic, started 24 weeks on Harvoni 12-17-14 ,EOT-5 week = UND, 8-31-15 =UND , SVR-24 Baby YES! 
Rybronco


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Rob,

I understand your frustration. I'm praying you get an approval soon.

Just remember, things are changing very very fast and with the onslaught of new meds coming the market dynamics will not look the same even 3 months from now. Like "old" treatments of the past, Inf and Riba will be considered archaic and will no longer be the SOC.

I believe you have a great opportunity coming!

Rockon!



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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
aprileee


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So sorry to hear this Rob.....I hope you get your appeal or can hold off until the new meds come out. Just please try and stay positive and live healthy in the meantime. Everything happens for a reason?? :(

__________________

33 years old Genotype 3a NO luck with Peg & Riba in 2013 but am undetected after 2 weeks of Sovaldi with Riba 2014 :)
Scruffy


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Hi Bob

Sorry you got denied. Your in good shape to wait though. Don't worry with all the testing for baby boomers now I fear a lot of people are gonna find out they have hep c. The good part is the insurance co's that are thinking about filling there pockets short term are gonna figure treating now is cheaper than transplant later. While on the subject a few years ago a little girl needed a liver transplant. The insurance co denied her saying is was an experimental operation and they wouldn't cover it. Her parents fought and and won. Little girl died in the in the mean time. Now thats cold!!



-- Edited by Scruffy on Tuesday 8th of April 2014 03:01:57 PM

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Geno 1a null responder 2004 inter/riba   finished incivek,peg/riba 48 weeks May 17th 2014. undetect weeks 4-12-32.  EOT+7 undetect. EOT+24 SVR!!!!! EOT+!YEAR SVR!!!!
Fireman Rob


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Thanks Everyone,

Today is definitely one of those days of feeling lost and confused about which direction to go. You all provided some much needed support and great info.

i greatly appreciate all of my new friends.

-Rob



__________________

Age 33, Male. GT-1 for ten years. Diagnosed in March, 2014.

Treated with Sovaldi/Olysio: SVR 24 on February 16, 2015!
OldenSlow


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Hi Rob  -  Sorry for the disappointing news. I'm gonna chime in on the side of those suggesting you wait. From one of your earlier posts, it seems your liver is in good shape. That's a major bargaining chip in this scenario. As Tig mentioned, there's going to be a brand new ruckus over coverage, etc. later on this year, but eventually things will resolve. The various payers can't continue to treat by medical necessity only. It makes no financial sense in the long run.

Lee  -  Thanks for the link to UHC guidelines. Good stuff.

wayne



__________________

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

 
Caryn


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Keep fighting! I read somewhere where the same thing happened to someone else and they won after the appeal. Also, can your doctor fight for you? When my doctor initially told me about the treatment, he said they would fight and keep fighting if they had to. Good luck and I am sure you know there is another excellent treatment just right around the corner! 



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1a, CT. Incivek triple 1/2013, vl 810 @ 2 weeks, 610 @ 4 weeks, 3000 @ 8 weeks, tx stopped. 

4/2014 - tx with Sovaldi/Olysio/Riba. VL 39 mil. - VL 230 @ 1 week, VL 40 @ 3 weeks, 5 weeks UND, EOT - UND, EOT @ 4 weeks UND, EOT @ 12 weeks UND!
jimbob


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Hi Rob.

I know starting treatment and preparing for it can be very stressful. So I can just imagine want it's like to have the rug pulled out from under you. I perpared for years. Tried serveal years ago to do the conventional, that didn't pan, tried a few years ago for the Incevik, decided against it. So I ended up with the Sov/Inf/Rib, which,all said, was the better choice. Sometimes, better things come from rejection or what appears to be bad news. Keep your chin up and just keep plugging along. Hopefully, something better is on the way. I'll be rootin for ya.

Good luck Rob.

jimbob



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jimbob: 64 y/o, GT 1A, F1-F2, diagnosed 1996. Since 1970. SOT 3.5 mil VL on 3/10/14 with Sov/Rib/Peg for 12 weeks. Tx naive. UND @ week 4,8,12. EOT 6/2/14.
Enavigo3891


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Hey Rob - I am sorry to hear that, I know you were very hopeful (understandably) that it would go through. I am with Tig though as far as waiting. I know that this is all still very new to you and I'm sure "just get rid of it" is still on the forefront of your mind but if the payment assistance programs aren't enough to help you float the treatment you want, and you're healthy, I would seriously consider holding off treatment. There are great things on the horizon. I think I told you, I did the same. Over the years my labs continued to show that I was in good condition so my ultimate plan was to hold off treatment until I was either REAL sick or an interferon free treatment came up for GT2's.  Thankfully the latter came first but it's something to look into. Keep your head up!! 



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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

 
Tig


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Hi Rob,

Sorry to hear about this, but I'm not surprised either. I'm reading about more and more scrutiny (?) being given to these drugs due to their cost, off label approaches and the petty bickering over this study and that...  Of course it's absurd and now with the new fast track approval by Gilead for their new super blockbuster, Sovaldi and Ledispavir, you're going to be witness to a completely new and heated discussion over pricing and approvals for treatment. It's all about the money unfortunately, at least in the USA and EU. If you're able to wait, it might prove to be worth the delay. This new treatment has shown 100% cure rates in some studies in as little as 6-12 weeks. Since Sov/Led is a single pill, from a single manufacturer, the off label argument will be a mute topic.

Aside from that, i want to remind you of the payment (treatment) assistance programs we have links to on the forum in the Knowledge section (also a link in my signature block). Keep us informed Rob, good luck.

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!

Hep C FAQ   Lab Ref. Ranges  HCV Resistance

Signature Line Set Up/Abbreviations   Payment Assistance

 
JoAnneh


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Hope you find treatment soon!
What a disappointment you have experienced.
I did the old school 48 weeks
But achieved SVR.
Keep on working hard to get coverage.
You are worth it:)

__________________

JoAnne

Genotype 1a, Triple therapy w/Invicek started May 19, 2012

DET 4 wk. UND 2,6,12,24 48 treatment. Achieved SVR 2013!
longld


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UHC has documented this well and very specifically (depending on your circumstances) at:

 https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Ox_MPUB_Future_Pharmacy/Notification_Sovaldi_514.pdf

 

'Based on the evidenced-based guidance available as of 

March 2014 from professional specialty societies and physician subject matter experts, 

UnitedHealthcare will provide benefit coverage for Olysio or Sovaldi in cases of genotype 1 

hepatitis C infection when there is documented evidence of stage 3 or stage 4 hepatic fibrosis. '

 



-- Edited by longld on Monday 7th of April 2014 08:18:27 PM

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62 Yrs Old, CHC Geno 3, Cirrhosis, Kidney Transplant (13 yrs), On Sovaldi/Riba Treatment (24 week) since Feb 01,2014

Viral Load 7M on 1/8/2014,  UND at EOT 7/18/2014
Fireman Rob


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Hi All,

Well- at first look, Sovaldi and Olysio were both covered by my insurance company (UHC) but now they have updated their new "treatment guidelines" and I was denied treatment today for both meds.  Apparently the only treatment option covered now is the "old school" Peg/Rib. 

I'm so bummed out about this news!  Now I'm back at square one so I'm applying for all of the assistance applications I can find and have already started the appeal process for the denial.  I was really optimistic that more insurance companies were covering Sovaldi but that's apparently not the case now.  Two weeks ago it was covered and today it's not!  Pretty ridiculous considering the company gets a 23% discount for Sovaldi alone (in the media).

Hopefully there's better news for those of us with "the best" insurance in the future.  Good luck everyone and I'll keep you posted on what I encounter to help others seeking similar treatment options.

Best,

-Rob



__________________

Age 33, Male. GT-1 for ten years. Diagnosed in March, 2014.

Treated with Sovaldi/Olysio: SVR 24 on February 16, 2015!
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