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Hep C Discussion Forum -> On Treatment -> Health Insurer refuses to cover cost of Sovaldi
Post Info TOPIC: Health Insurer refuses to cover cost of Sovaldi
Lowrider


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RE: Health Insurer refuses to cover cost of Sovaldi
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I received word yesterday through a friend of my brother who is a Hep C researcher for a NGO in Thailand that both Olysis and Sovaldi are not available there. Puts that option to rest. As far as income, I am retired (67) and the income is fixed. The intension is to keep pressure on the insurance provider ( a health plan for local Bay Area county workers and retirees ) and let it play out for the summer. A notice came in the mail late yesterday informing me that the monthly health care payment has been increased 75 bucks. You just have to laugh sometimes.



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"You can't count the miles until you feel them." T Van Zandt

68 yrs old, HepC 1A, relapsed 6 months post Victrelis/Interferon/Riba. Fibrosure F4 currently using Harvoni
Dzdayscomin


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I was denied twice, and thought that was it, then about 40 days later and after the two appeals during that time.... out of blue, the Nurse Coordinator calls me and says you have been approved for the S/O off label combo.

I think they try and deny it and see if you will give up, all while they search for a reason that you shouldn't get it, and, or meet the current criteria for off label use and interferon intolerance, then when they realize they can't fight it anymore they approve it.

I had BCBS ins. with express scripts so I thought for sure I wasn't getting it.

It took two to three weeks after the second appeal for that to happen.... so hang in there and if you can wait for the upcoming new all in one that will be better than taking chances overseas. JMHO



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Fireman Rob


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Lowrider,

I feel your frustration with insurance as I have spent the last four months there myself. I guess I was was fortunate enough to make less so the drug companies helped me but otherwise my insurance is proving to be a waste for HCV. 

It looks like Isis and Tig have pretty much covered it but I would keep on appealing, and appeal each and every denial with justifications contrary to their reason for denial. At some point a decision must be made to end this ridiculousness but until then, it looks like it's up to market competition to drop drug prices.

You will find a way to obtain Tx soon I'm sure. Try to remember all the options on the horizon.

Best of luck!

-Rob



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

Treated with Sovaldi/Olysio: SVR 24 on February 16, 2015!
Isiscat2011


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Lowrider wrote:

My income is too high for financial assistance and I am fairly pissed off being I pay a significant monthly premium for health care coverage and now denied coverage. 

I hear you loud and clear.  This isn't a subject discussed too often but you really get screwed if you earn too much for assistance but not enough to pay cash for these ridiculously high priced drugs.  Plus you get hit with exorbitant insurance premiums and co-pays and deductibles.  In the 12 months following my hepc diagnosis, which included tx, my portion of health care costs was about 40K, and my insurance premiums were another 14K (high risk due to my hepc diagnosis).  And, that is what it costs when you have what is supposed to be good health care coverage.    

It is sometimes better to significantly decrease your income when you have an illness that requires substantial health care and pharma costs--which can lower your premiums under the ACA and could make you eligible for some assistance--but you can't significantly reduce income unless you have substantial savings to live on or unless you can significantly decrease your living expenses.  

60% of all bankruptcy filings in the US are due to health care costs and now I can see how that happens.    



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Diagnosed in 2011, Incivek triple in 2011, tx discontinued, Genotype 1a, CT, VL 7mill, cirrhosis dx in 2012, age 67, waiting for new DAAs.
Isiscat2011


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Lowrider wrote:

To be clearer, my doctor is working on this and the last refusal for coverage was Thursday. He hasn't recommended going abroad for treatment and I am waiting for a more detailed report from the advisory committee so he can evaluate it and see if another appeal can be made. He did mention the possibility of requesting an independent review.

If your doctor is already on board with the appeal then by all means continue that process.  I just hate to see people getting stressed and feeling defeated when the very near future looks so much brighter than the moment.  In all reality, waiting a matter of months is unlikely to make any negative difference in terms of outcome, and it could make a positive difference.  Good luck!



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Diagnosed in 2011, Incivek triple in 2011, tx discontinued, Genotype 1a, CT, VL 7mill, cirrhosis dx in 2012, age 67, waiting for new DAAs.
Lowrider


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To be clearer, my doctor is working on this and the last refusal for coverage was Thursday. He hasn't recommended going abroad for treatment and I am waiting for a more detailed report from the advisory committee so he can evaluate it and see if another appeal can be made. He did mention the possibility of requesting an independent review. The political landscape in Thailand, particularly Bangkok, seems dramatic, but business goes on as usual in that country. Too much at stake their from foreign business investments, etc. It is a much more stable country in spite of what is read in the media. Waiting for changes in insurers coverage policy and new drugs coming online seems to be reasonable at this point. I am just looking for good info and at alternatives that might be a way to go. My income is too high for financial assistance and I am fairly pissed off being I pay a significant monthly premium for health care coverage and now denied coverage. The information posted here has helped me understand what is up. Thanks.



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"You can't count the miles until you feel them." T Van Zandt

68 yrs old, HepC 1A, relapsed 6 months post Victrelis/Interferon/Riba. Fibrosure F4 currently using Harvoni
Tig


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Hi Mark,

I have to agree with everything Isis has mentioned. Your doctor should be the one in charge of getting this ball rolling and if s/he isn't sure and already recommending you travel to Thailand, that just went through another coup, I'd seek another opinion.  We put together a fairly comprehensive payment assistance thread here on the forum and I recommend you talk a look at it. There are several organizations available the can help you financially when insurance is fighting you or not available. The manufacturers are also helpful if your income is limited. Our thread is in the Knowledge section and you can find it via the homepage. Good luck...

Tig



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Tig

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Isiscat2011


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P.S.  

When the S/L combo is approved in October the "off label" barrier of the S/O all oral combo will be removed because the S/L combo will be on label. Additionally, the S/O combo may be approved on its own.  The off label barrier is significant both in terms of doctors who are willing to prescribe off label and insurance cos willingness to pay for off label. 

An update to the AASLD tx guidelines should follow shortly thereafter which will change the SOC to all oral DAAs.  Docs will be prescribing them by the truck loads and insurance companies will have to pay for SOC tx.  The problems we are seeing now with insurance co payments will ease up and gradually be eliminated completely.  



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Diagnosed in 2011, Incivek triple in 2011, tx discontinued, Genotype 1a, CT, VL 7mill, cirrhosis dx in 2012, age 67, waiting for new DAAs.
Isiscat2011


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Lowrider wrote:

Had biopsy maybe 10-11 years ago which was negative for scarring. No fibroscan as yet. Recent ultrasound was normal. Interesting that the health care provider insisted on a Fibrosis blood analysis commonly known to be erroneous. 

________________________________________________________________________________________________________  

 

It is also interesting that your doctor doesn't know "the next step."  He or she should be less perplexed given that your situation is not unusual.

So, you probably do have some fibrosis by now, but that is no reason to panic or start entertaining ideas of flying around the world to obtain immediate tx. Many nationally and world renowned hepatologists are recommending that patients wait for the soon to be arriving all oral DAA combos even when their patients have cirrhosis.

In four months the Sovaldi/Ledipasvir combo will be approved.  Based on the clinical trials that combo is your best bet anyway, both in terms of safety and efficacy.  Other DAAs will be approved shortly thereafter.  We should see an immediate cost reduction in all oral tx because the S/L combo will be priced less than the S/O combo.  As more DAAs are approved the costs will be decreased even more.  There may be some price negotiations between pharma and insurance companies.  The result will be that insurance companies will begin opening up their check books.  

By the time you could get something going in Bangkok the market here will change in your favor both for what is available and what it costs.  It is changing as we speak.  I would recommend that you take good care of your health and chill for a while.   Go ahead and have a fibroscan or a biopsy in the meantime.  That is the best short and long-term solution, imo.  Best regards. 



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Diagnosed in 2011, Incivek triple in 2011, tx discontinued, Genotype 1a, CT, VL 7mill, cirrhosis dx in 2012, age 67, waiting for new DAAs.
Lowrider


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Had biopsy maybe 10-11 years ago which was negative for scarring. No fibroscan as yet. Recent ultrasound was normal. Interesting that the health care provider insisted on a Fibrosis blood analysis commonly known to be erroneous. 



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"You can't count the miles until you feel them." T Van Zandt

68 yrs old, HepC 1A, relapsed 6 months post Victrelis/Interferon/Riba. Fibrosure F4 currently using Harvoni
Isiscat2011


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Lowrider wrote:

I know what the cost for Sovaldi is here in California and pretty sure that is the reason my health care "provider" is refusing to pay it. If the cost in Bangkok is significantly less I can go there if needed provided they are using Sovaldi for treatment.  My Fibrosis score is .85 Stage 4 Cirrhosis, Necroinflammatory Activity is .71 Severe Activity, Alt 88, GGT 119. My viral load runs in the mid to high 4mil range. I received a coupon for payment of the Olysis but was turned down for assistance for Sovaldi.

 That fibrosis score appears to be based on a fibrosure blood analysis which is notorious for being wrong.  Have you ever had a biopsy or fibroscan?



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Diagnosed in 2011, Incivek triple in 2011, tx discontinued, Genotype 1a, CT, VL 7mill, cirrhosis dx in 2012, age 67, waiting for new DAAs.
Lowrider


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I know what the cost for Sovaldi is here in California and pretty sure that is the reason my health care "provider" is refusing to pay it. If the cost in Bangkok is significantly less I can go there if needed provided they are using Sovaldi for treatment.  My Fibrosis score is .85 Stage 4 Cirrhosis, Necroinflammatory Activity is .71 Severe Activity, Alt 88, GGT 119. My viral load runs in the mid to high 4mil range. I received a coupon for payment of the Olysis but was turned down for assistance for Sovaldi.



-- Edited by Lowrider on Saturday 7th of June 2014 06:56:07 PM

__________________

"You can't count the miles until you feel them." T Van Zandt

68 yrs old, HepC 1A, relapsed 6 months post Victrelis/Interferon/Riba. Fibrosure F4 currently using Harvoni
Isiscat2011


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Hi Lowrider:

1) What is the condition of your liver/health? 

2) Are you eligible for any patient assistance programs to help cover the cost of Sovaldi?



-- Edited by Isiscat2011 on Saturday 7th of June 2014 06:47:07 PM

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Diagnosed in 2011, Incivek triple in 2011, tx discontinued, Genotype 1a, CT, VL 7mill, cirrhosis dx in 2012, age 67, waiting for new DAAs.
Finbar


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The cost for the OLYSIO IS 66,380 for 12 weeks and the SOVALDI is about 86,000 for 12 weeks 



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Barry C
Finbar


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I'm also waiting for my insurer s ok to let me start both drugs. I know how expensive they are as I'm on anti rejection pills already . Guess I'm costing them a fortune, but that's what insurance is for. I was told there are no side effects for these two drugs is that true



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Barry C
Lowrider


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Hi folks,  haven't been here for awhile. I was here during triple treatment with Victrelis. Relapsed six months post treatment. I was with Kaiser then. Now I am with a different provider and my doctor has prescribed Olysis and Sovaldi. They have refused coverage initially and just refused again after providing them with more information they requested on appeal. My doctor and I don't really know what the next step, if any, will be. I was given a coupon for the Olysis but Sovaldi is the problem. One possibility is Thailand. My brother and his family live there. He recommended Bumrungard International Hospital in Bangkok. This is a well regarded hospital in Bangkok that services most of the American ex-pats working in the tech industry there. I have contacted them but don't know if Sovaldi is available there yet. Still waiting for my request for treatment to be reviewed by their GI Clinic. Don't know what the cost is yet either. Any advice or thoughts? Thanks. HepC genotype 1a.



__________________

"You can't count the miles until you feel them." T Van Zandt

68 yrs old, HepC 1A, relapsed 6 months post Victrelis/Interferon/Riba. Fibrosure F4 currently using Harvoni
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