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Hep C Discussion Forum -> New Members Area -> New And curious about insurance coverage.
Post Info TOPIC: New And curious about insurance coverage.
Lindsmatt52


Senior Member

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RE: New And curious about insurance coverage.
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Hi Guy-  I do have BCBS and can share my experience with you.  My doctor initially wanted to put me on Zepatier and my insurance denied it.  After testing resistant to Zepatier, my DR put me on Epclusa, which was also denied.  My liver enzymes were fairly normal,  I have F1-F2 fibrosis and a high VL of 7.5m, so I wasn't as "sick" as some, which is why I think I was denied.  My DR sent in an appeal and I sent a letter as well (which I think helped immensely) and I was approved.  As Canuck said, each state is different and you may have to jump through some hoops but do not give up!  You will eventually find a way to get the meds that you need.  Good luck!



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64 y/o female, no idea how HEP C contracted

diag. 6/2017, GT 1a, VL 7.64 mil

Fibrotest-.41 (F1-F2) ; Actitest/Metavir 0.18; Apri: 0.266

Mutations detected: Q30H/Y, H58Q

Alt-33;  Ast-28

4 week:  VL<15; ALT-7 AST-11: 8 week: VL-UND, ALT-9, AST- 9

 Epclusa SOT 8-31-17; EOT 11-22-17

Lindsay
robertsamx


Guru

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Posts: 915
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Guy, 1.5 years ago you had to jump through all the hoops to get Harvoni,all the qualifications the insurance company's put on patients was ment to slow down the application process. The insurance company's were having trouble spending one thousand dollars a pill knowing it would take 84 pills or more to treat HCV. They knew there were more drugs in the pipeline so they were dragging there feet hoping the competitors would drive the cost down. They got away with it for a while. This cought the attention or our U.S. Congressman and Senator's and the insurance company's  had to back down and conform to public and government pressure. Now days you can be assured that you will get approved!   It might not be Harvoni, but they will approve a R/X that is best for you. Hang in there Guy. Start banging on there door.  RC 



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 M-68, 3 Treatments)( SOF-RIBA 2014)(SOF-RIBA-PEG 2016)(HCC 2016) (LIVER TRANSPLANT 8-2017)(VOSEVI-RIBA 2017)   SVR-12. 3-13-18   
polosilver


Senior Member

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Posts: 245
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Hi guy -- One thing to ask for is your plan's drug formulary. Here in the states, the companies publish formularies which tell which drugs that are covered under your plan. If a drug is not on the formulary, it is considered non-formulary and then is more difficult to get approval for it. Typically they publish new formularies every year, so ask for the one for 2017. The drug I take Harvoni, was only added to the formulary for my insurance plan in 2017. By checking the forumulary you will at least know what drugs for HCV are covered under your plan in advance.

Here in the US the treatment path typically depends on test results and the state of your liver. My viral load was low, but my liver enzymes had been up and down for several years (sometimes in the 100's and others times in the 50's) and I had F2 moderate fibrosis, so I qualified for treatment right away. It depends on your lab tests, doctors, insurance, etc. I don't have BCBS so can't speak to that in particular.

 



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New: Hepatomegaly 07/30/2019, AST 29 & ALT 15

Female,1a,F2 mod fibrosis,HCV 06/2017,SOT 08/04/2017, Harvoni

HCV VL 414,000, AST 54, ALT 74.  4 weeks AST 34 and ALT 31, SVR, Jan 2018. 

12 week EOT, AST 20 & ALT 23 and still VL UND.

Club Zero Member.

 
Canuck


Guru

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Posts: 3249
Date:
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Hi there guy!

Glad you've stopped in and glad to meet you. If you had any other question I would be more than glad to take a stab at it and try to help with whatever I know, but I am in Canada and i have never been able to master the medical system (s) you have down in the US, to figure out how they best work. There are many members here, who are in the US, and I am sure one of them will be along right shortly to help you sort through this info. Shoot, I can't even figure out my medical system(s) here.

All I know, is that in a "perfect" world, when one has HCV, we SHOULD be able to get in the treatment queue right away. Becasue of money/insurance it does not always work that way, as many of us have found out.

It used to be (not that long ago) you had to have proven Fscores  of 3 or over (showing the level of scarring/ firmness/fibrosis/injury in your liver) determined by "fibro-scan" or by various blood tests, or by liver biopsy (not done as much nowadays), to "satisfy" insurance that you should have treatment now versus later. Subsequntly, we have started to see some improvements in these "obstacles" to receive treatment in a more timely fashion. Some people being told they need only be F2, or more. Some people seem to be getting accepted for treatment right away (relatively). 

Hopefully one of the others here, more well versed about Blue Cross/Sheild will have more specific info for you than I! I do still think tho, that WHERE you live, which "State" still has a large bearing on things.

Please do share a bit more about your health and situ, we would all be more than happy to assist where we can. C.



__________________

HCV/HBV 1973. HBV resolved. HCV undiagnosed to 2015. 64 y.o. F. Canada.

GT3a, Fibroscan F3/12 kPa - F4/12.6 kPa, VL log 7.01 (10,182,417), steatosis, high iron load.

SOF/VEL with/without GS-9857 trial - NCT02639338.

SOT March 10 - EOT May 5, 2016 - SOF/VEL/VOX 8 week trial.

 

(SEE UPDATES IN BIO)
Worriedguy


Newbie

Status: Offline
Posts: 1
Date:
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Hi I am new to the forum and have a question about insurance coverage. Specifically, I have Federal Blue Cross Blue Shield, the basic option. I just got diagnosed today. I was wondering how advanced your hep c has to be in order to get prior approved for Harvoni. Has anyone had experience wit



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