Hepatitis Forums
Hepatitis C Main Forums => Considering Hepatitis C Treatment => Topic started by: Coach Mike on August 14, 2015, 08:20:23 pm
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My insurance company, ARBenefits (Health Advantage, Arkansas), considers patients with severe extra hepatic manifestions (EHM) as candidates for treatment coverage regardless of fibrosis score. I would like to compile a list of other insurers who have similar options in their treatment criteria. This would allow people seeking treatment coverage based on EHM to cite the various insurers by name who consider EHM a legitimate reason to approve HCV treatment.
Thanks,
Coach Mike
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For those who (like me), had not heard the term "extra hepatic manifestations" before, I just found this clear fact sheet that lists the manifestations:
http://hcvadvocate.org/hepatitis/factsheets_pdf/Extrahepatic.pdf
Coach Mike, good thinking -- such a list could be helpful to many people who turn to this forum. I don't know about my insurance company's policy, but I'll try to find out.
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Glad to help. There is so much more to consider when dealing with HCV than just a fibrosis score.
Mike
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I think many insurance companies are keeping that kind of information close to the vest. May be difficult for us mere mortals to obtain
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Coach Mike , How were You able to get the info.?
BTW Lynn K. I've been able to get a little more sleep the last couple of nights so My pea brain in comprehending things a little better. I.E.getting an idea what all I need to put on My signature,looking at several to get an idea. Woman You are a beast!!!
A real hep Super Hero!!!
Mike when I go in for labs Monday I'll ask the insurance lady if she is in. I was so happy with the whole staff when it only took a week from applying to having the first Harvoni script in My hand I bought them all lunch. They really like Me big time & are always checking on Me & sending a card or two.
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Believe me when I say I know people who went much further than I down this dark road. Some did not come back and some just barely made it back. I have been very lucky compared with them.
I am where I am because I am standing on the shoulders of giants.
Best to all
LK
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My hat is tipped to You. I am in awe of Your modesty after such a difficult journey that You endured!
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From my understanding, severe extra hepatic manifestions (EHM) is also listed on the guidelines from the AASLD that list those that should receive priority for treatment. A large number of insurance companies have adapted those guidelines as criteria for treatment approval - which is mostly those with cirrhosis or severe EHM. (Even though the AASLD has now added that all with Hep C should be treated if their doctor recommends it, many insurance companies are sticking with the original guidelines - for obvious financial reasons).
In my appeal to my insurance company (HMSA) who uses those guidelines as a criteria for treatment, I attempted to list and qualify other hepatic symptoms even though many are difficult to prove and don't always meet the "severe" criteria. They were unmoved, relying solely on the Fibrosis score of a 3/4 for consideration even though the others were listed. That was my experience. But others may have a different experience so it's worth the effort to get approval I think.
Luckily and gratefully, I was able to get the medication through Gilead Support Path. My goal was try everything, leave no stone un-turned and get the treatment any way I possibly could. Persistence is key.
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And, one more thing... I was able to get the insurance approval criteria for treatment and drugs available for treatment by my insurance company by simply requesting it. I did that after the initial denial. (Requesting it before the first denial would have been better.) My local pharmacy got it for me too. I'm sure the prescribing physician's office has access also.
I'm not sure but I don't think they can deny you the information on how they determine treatment approval. In some cases, it may not yet be on their approved drug list.
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I asked for my insurer's criteria for treatment many times. Their answer was always the same: "Have your doctor contact us". After trying to explain to some faceless voice over and over that my doctor was busy and I was their customer and I paid the premium, they still refused to tell me. So, since my insurance is managed by the state, I requested the criteria for treatment under the Freedom of Information Act and had it in the mail in a week. There, under section 7A, HCV treat criteria was this:
7. "Patients with extra hepatic manifestations of chronic HCV infections are candidates for therapy regardless of corresponding Metavir score..........."
So congratulations to those who have been cured or are in the process!! To the rest of us I say, "Research, pressure, post and persevere".
We need to fight for our right to treatment. There are too many of us for them to keep ignoring our plight.
Mike
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My insurance company, ARBenefits (Health Advantage, Arkansas), considers patients with severe extra hepatic manifestions (EHM) as candidates for treatment coverage regardless of fibrosis score. I would like to compile a list of other insurers who have similar options in their treatment criteria. This would allow people seeking treatment coverage based on EHM to cite the various insurers by name who consider EHM a legitimate reason to approve HCV treatment.
Thanks,
Coach Mike
Coach, as promised, I have now obtained my insurer's prior authorization of benefits guidelines for approving Harvoni. Anthem doesn't consider patients with severe extra hepatic manifestations as candidates for Harvoni coverage, except for the following: (a) Type 2 or 3 essential cryoglobulinemia with end-organ manifestations (for example, vasculitis) or (b) Glomerular disease [proteinuria (greater than 300 mg/day), nephrotic syndrome, or membranoproliferative glomerulonephritis]. (a) is listed on the HSCP Fact Sheet of EHMs. (b) is not, but kidneys aren't the liver, so I'm counting glomerular disease as extra-hepatic.
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Thanks Gnatcatcher,
That helps. Anthem is big time.
I am happy to see you are getting the treatment you need!
Mike