Hep C Discussion Forum

masbirdies · Member

RE: Harvoni Co-Pay Question

Matt Chris · Guru

Hey All

I believe in most cases the biggest delay in getting approved is the incompetence or lacking of caring of the medical side i.e. Doctors, nurses, prior approval depts. not either knowing or not interested enough to figure out whats required to follow through on initial requests for approval and appeals.

I experienced this first hand with my Doctor, I had to entirely take responsibly for every aspect of the appeal process after the Doctor screwed around for a month trying to get a peer to peer review on the first request.

The forum had some great posts about how to write an appeal letter and all its necessary content, which helped greatly.

matt

Tig · Admin

Lon,

I have to wonder if all the hoops and obstacles, even the most minor are because these insurance companies and the state/federal agencies were ill prepared for the onslaught of claims and medicine costs. The actions you've dealt with are simply ways to delay their responsibility. I believe that's the primary reason. I shake my head and go back to doing what I can to see that you all get what you deserve. I pray and will continue to advocate for the changes necessary to bring treatment to everyone needing it. Keep up your hopes and spirits my friends, we'll get through this together!

Tig

Lon · Veteran Member

Thanks for sharing your experience. I wonder if insurance companies and doctors offices have this high percentage of error all the time or is it only for Harvoni. So much of the problem as you stated, is with failed fax transmissions, e-mail and phone message problems and just wrong information such as my insurance company directing me to two specialty pharmacies that they later denied.

hepCFREEwanab · Veteran Member

We are using the $5.00 co-pay for the Harvoni. When I originally spoke to them, they explained how the coupon was valid for 6 months and would cover up to $23, 000 against co-pays!

Mena

Stormy · Veteran Member

Hi Lon,

Oh, I feel your frustration. I am blown away by the hoops we jump thru and all the speed bumps in between. I have been waiting over a year for this process. Started with my doc telling me to wait til fall, 2014. Then it was 4 weeks for approval, (that didn't happen) then 2 months for 3 denials, and one month for docs office, Acarria and me to square away paper work, (not sure if that happened, due to unknown emails, fax machine problems, wrong ss#, etc.). Guess I'll be calling again on Monday. How long Gilead takes? We shall see.

But, I woke up this morning, the sun was shining, spring around the corner. I'm going to enjoy my time.

Stormy

Lon · Veteran Member

Thanks for the info. I'm with my 3rd specialty pharmacy now and I'm waiting for processing and hope to hear some good news next week.

My insurance company referred me to the 1st specialty pharmacy and then turn around after a week and denied my claim stating that it wasn't the right pharmacy. That killed 10 days. Then the insurance company told the 1st specialty pharmacy to fax my script to a 2nd specialty pharmacy. After a week, my insurance company told me that the 2nd pharmacy wasn't the right one either and referred me to a 3rd specialty pharmacy. This wasted another 10 days. The 3rd specialty pharmacy sat on it for a week because my insurance company failed to provide them with the approval authorization needed to start the pharmacy process. After doing a conference call yesterday with the insurance company and the pharmacy together, the pharmacy is reporting that they have what they need to finally begin their verification processing. The verification process will take 7-10 days and when that's finished they can begin processing the prescription assuming everything confirmed correctly. The pharmacy went on to say that they generally don't take coupons and my insurance company won't allow me to take the prescription elsewhere. I plan to call Gilead on Monday and being the what-if discussion in the event that the pharmacy refuses to accept the Gilead co-pay coupon.

Rewinding to the beginning, I submitted my initial prescription authorization on January 6th. The month of January was wasted because the people in my doctors office at Mass General Hospital were not sending the right paperwork to the insurance company. Because the paperwork submitted was inadequate, my first claim was denied. Because I was denied, my insurance company refused to accept supplemental documentation submissions. This required a new prescription authorization by my doctor which was also handled poorly resulting in a second denial. The first denial was because my viral load failed to be faxed to the insurance company and the second denial was because I needed a Fiberscan which my doctor's office wasn't aware of. I had the Fiberscan and my doctor's office submitted the results but the lab results were rejected because my claim was once again in a denied and the insurance company stated that no additional document submissions were being accepted because of the denied status.

In summary, I spent the month of January trying to get my paperwork out of my doctor's office and to my insurance company and the month of February was spent bouncing around from pharmacy to pharmacy because my insurance company couldn't get it right.

I'm not putting this all out there to vent (well, maybe a little) or complain but to illustrate some of the frustration that needs to be dealt with in getting this medicine. To anyone just starting the process and for what it's worth, in my case I've spent 1-3 hours a day pushing this through for the past two months. I am now entering my third month and still haven't received my medicine. This has been a great opportunity to develop my patience and tenacity.

Thanks everyone for all the good advice. Support forums like this are essential to navigating the red tape involved with getting this medicine.

Have a great day.

Lon

SwimmerChic · Member

Lon,

Mine says it's good for up to 6 months after the initial fill. The only scary thing is the paperwork that comes with the bottle says my copay is something on the order of $3,975 and they've charged my credit card. In actuality they only charge my card the $5 copay.

I think I'd (nicely of course) ask to speak with a supervisor at specialty pharmacy. Do you have specialty pharmacy's dispensing pharmacy's number? Those folks have been quite easy to work with. When I called for my 2nd month script I asked if they needed my coupon numbers again to apply and they had them and assured me they would. There were no questions about whether they'd apply it for my 8 week tx.

Don't give up! It can be frustrating, but keep advocating for yourself! When my gi said he was submitting for my tx I gave them 5 weeks (Christmas was in the mix) then started calling both the doctor's staff (useless) and the pharmacy at least twice a week until I received my first shipment.

Good luck!!!

Tig · Admin

Lon,

I would also call this number and ask the representative why they are honoring other 8 week courses of treatment and not others! Get a name, number and ask for a supervisor before accepting no for an answer.

Call HARVONI Support Path at 1-855-7-MYPATH (1-855-769-7284)

Tig

Tig · Admin

Hey Lon,

I refer you to the Payment Assistance link in my signature. If Gilead is going play that game, I want you to contact the org. in my list called the PAN Foundation. They have been very helpful in helping with these costs. Just do it! smile

Tig

Lon · Veteran Member

Thank you.

masbirdies · Member

Mine says good for up to 25% of the 12 week cost. I don't see anything that eliminates the discount for 8 weeks. I am on 8 and my co-pay coupon was accepted. Saved me $3300

Lon · Veteran Member

Hello Everyone,

I'm waiting for the specialty pharmacy to finish my Harvoni prescription processing. When they received the prescription I called and gave them the 5$ Gilead co-pay coupon information. Tonight when I called to check on their progress they indicated that the 5$ co-pay coupon might not apply to my prescription as I am only approved for 8 weeks and the co-pay coupon states it is only good for 12 weeks of therapy.

In the event that I have to pay the full co-pay out of pocket, I was wondering what others were experiencing regarding their out of pocket expenses for the prescription.

Thank you,

Lon

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