Hepatitis Forums

Hepatitis C Main Forums => Considering Hepatitis C Treatment => Topic started by: lporterrn on January 13, 2016, 01:16:35 pm

Title: Insurance Companies' Coverage Criteria for Hepatitis C Treatment
Post by: lporterrn on January 13, 2016, 01:16:35 pm

I thought it might be useful to have the hep C coverage criteria in one thread listing all the insurance companies, state Medicaid programs, specialty pharmacy, and other payers. Please help add your sources and update if needed:

Aetna: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html (http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html)

Anthem: https://www.anthem.com/provider/noapplication/f0/s0/t0/pw_e225443.pdf (https://www.anthem.com/provider/noapplication/f0/s0/t0/pw_e225443.pdf)

Caremark http://www.caremark.com/portal/asset/FEP_Criteria_Harvoni.pdf (http://www.caremark.com/portal/asset/FEP_Criteria_Harvoni.pdf)

Cigna https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/pharmacy/ph_1316_coveragepositioncriteria_hepatitis_C_therapy.pdf (https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/pharmacy/ph_1316_coveragepositioncriteria_hepatitis_C_therapy.pdf)

State of California Dept of Health Services: http://www.dhcs.ca.gov/Documents/Hepatitis%20C%20Policy.pdf (http://www.dhcs.ca.gov/Documents/Hepatitis%20C%20Policy.pdf)

United Healthcare https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Pharmacy%20Resources/Med_Nec_Harvoni.pdf (https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Pharmacy%20Resources/Med_Nec_Harvoni.pdf)

Title: Re: Insurance Companies' Coverage Criteria for Hepatitis C Treatment
Post by: Joe NM on January 13, 2016, 04:13:04 pm

I'm still trying to figure out Express Scripts, if you ever find anything on them...They still cover Viekira Pak for everybody, no restrictions (if you have genotype 1). Up until a couple months ago they were denying all of my clients for Sovaldi unless they were F3-F4...but then they started approving everybody for Sovaldi and Daklinza...so no more discriminating against genotype 2 and 3? Sure hope this lasts.

Title: Re: Insurance Companies' Coverage Criteria for Hepatitis C Treatment
Post by: FutureThinker on January 13, 2016, 08:16:39 pm

Thanks much, Lucinda -- excellent information.  FT

Title: Re: Insurance Companies' Coverage Criteria for Hepatitis C Treatment
Post by: Allen Cunningham on January 14, 2016, 12:10:53 am

Diagnosed 8/97 with HepC
Liver Transplant 7/2004
Genotype 1b, Biopsy:12/2015: F-0, Slight Inflammation, TX Naive
v/l: ~600,000 - ~1,000,000 ALT: 26, AST: 26
Starting 12 wks Harvoni in Jan 2016

I have Medicare with Tricare using Express Scripts. I was OK'd for 12 weeks Harvoni with no copay's even though no fibrosis.

I think post-transplant patients are near the top of the list per AASLD criteria

Title: Re: Insurance Companies' Coverage Criteria for Hepatitis C Treatment
Post by: malou on January 18, 2016, 09:43:07 pm

 Joe in NM, I am also in NM.  I was told last Friday that there was no way Express Scripts would ever cover me for treatment, since I had no fibrosis and my labs were so good.  Well according to my guestimate, I think I have had it since 1996.  Lucky that I am not having problems, but still I wanted to treat it.

So, about a month ago, I ordered Twinvir from Bangladesh and paid $1440 for it.  Started on the 1st.  I must say that I am having absolutely no side effects, but am feeling wonderful.  All symptoms of arthritis and fatigue are gone.  I am swimming and hiking daily and have no pain when I wake up.  I was taking either Ibuprofen or Vicodin for my pain at night, but have not taken anything since the first of January.

Since I had two insurances (BSBC and Champva) I am canceling the BCBS tomorrow and in June I will qualify for Medicare.  The $300 per month that I pay for BCBS will almost cover the cost of Twinvir.  And, I understand that Twinvir is going down to $1040 at the end of January for anyone interested.  ML

Title: Re: Insurance Companies' Coverage Criteria for Hepatitis C Treatment
Post by: Allen Cunningham on January 19, 2016, 04:25:32 pm

Diagnosed 8/97 with HepC
Liver Transplant 7/2004
Genotype 1b, Biopsy:12/2015: F1, TX Naive
v/l: ~600,000 - ~1,000,000 ALT: 26, AST: 26
Starting 12 wks Harvoni in Jan 2016

Malou - So glad to hear you are getting treatment and feeling so good! What is Twinvir? Is it a generic version of Harvoni or Sovaldi? Do Hepatologist's and Gastro's recommend it?

I saw my Hepatologist today at UC San Fran, and I was worried she was going to put me on Harvoni plus Ribo since I am post-transplant, however she said I could start with Harvoni and they will do Virus levels every two weeks to make sure the virus level is dropping nicely, if not I might have to go on Ribo.

I just took my first Orange Diamond shhaped pill 10 minutes ago, it's quite a beautiful pill, however it doesn't look like $1125.00 worth!

Title: Re: Insurance Companies' Coverage Criteria for Hepatitis C Treatment
Post by: malou on January 19, 2016, 09:25:26 pm

Twinvir is the Bangladeshi form of Harvoni which contains Ledipasvir 90 mg and Sofosbuvir 400 mg.  It has been tested in Australia and found to be 99.9% pure (just like any medication manufactured in the US).  The Rx from my hepatologist was for Ledispasvir 90 mg and Sofosbuvir 400 mg, 1 tablet daily for 12 weeks.  Mine had a total cost of 1400 plus $40 shipping, and I believe that comes to about $17 per pill.  Since my insurance has refused any treatment, stating that I am not 'ill enough" even though I have had the virus since 1996, I had no other options.  Ml