Hepatitis Forums
Hepatitis C Main Forums => Considering Hepatitis C Treatment => Topic started by: BDK on February 20, 2015, 02:38:16 pm
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Hi there - does anyone know which insurance companies cover Harvoni for people with 1a with fibrosis scores of 0/1? I've been battling Anthem for over a year now, first for Solvaldi/Olysio, and then for Harvoni, with no luck - they are sticking to their "guidelines" of requiring stage 3 or worse.Thanks so much!
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Hi BDK,
Coverage decisions are based on an insurer's Medical Necessity guidelines, which are drawn from Usually & Customary treatment protocols that have been established by the medical community.
Medical Necessity (MN) is the process for determining benefit coverage and/or provider payment for services, tests or procedures that are medically appropriate and cost-effective for the individual member. (Note insurers do not deny treatment, rather they deny payment of treatment.)
MN decisions usually follow a least-invasive-protocol. For example, if a patient is experiencing minor shoulder pain, the protocol would indicate respite, physical therapy, pharmacological management, followed by additional diagnostics and possibly arthroscopic surgery.
In this example, the insurer would not automatically approve surgery if the other steps in the protocol were not ruled out.
Although HCV treatment is a little more complicated, MN protocols have been established by insurers for payment of HCV treatment and follow the same rational.
Since most, if not all, insurers require F3 or greater liver damage in order to approve payment of current HCV treatments, denials are more frequent than not if the patient doesn't meet this threshold. (There are some medical exceptions.)
Denials can be appealed; but the burden of proof falls on the appellant to demonstrate medical necessity and cost-effectiveness.
Unfortunately, it is the cost associated with current HCV treatment that is driving the MN approval guidelines, as well as empirical research & statistics that indicate upwards of 80% of those infected with HCV do not present with clinical symptoms and do not show liver damage or progression.
Once the cost of HCV treatment decreases and stabilizes, guidelines will be adjusted and more will be approved.
Hopefully, this will be in the near future.
Best wishes, Mike
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Thanks Mike. Has anyone with F0-1 had any success with any insurance company?
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Yes. There have been several approved with minimal 0-1 scores, who post on this forum.
I know it can be frustrating, but I would continue to fight for approval.
Best wishes, Mike
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Will keep on fighting - anyone who has had success, please could you post which insurance company it was with? thanks.
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Will keep on fighting - anyone who has had success, please could you post which insurance company it was with? thanks.
BCBS of Texas (Prime Theraputics) approved me for 12 weeks Harvoni in about 3 days. My doctor submitted for approval on Friday. I heard from the clinic pharmacy on Wednesday. I received first bottle of pills on Thursday morning and took the first one that evening. Was shocked how fast it happened.
VL=3.6 million
Grade 1, Stage 0, HAI=2/18
ALT avg=57, AST avg=42 (over 8 year period)
So sad that you are having to tap the brakes on treatment but I think this is temporary. You will get approved soon. I think within a year or two at the most, costs will have come down so much that approval will be a foregone conclusion. It will be like getting approved for treatment for high blood pressure. Keep fighting and good luck!
Bob
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Thanks for the encouragement Bob. I've been diagnosed since 1992, and never worried about it, fibrosis 0-1, despite 9 mill VL. ALT and AST always top end of normal. But its been so infuriating getting so many denials, denials of appeals, denials by Support Path etc, that I may give it a break for a while and just relax about it, and wait for the market to do its thing.
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Thanks for the encouragement Bob. I've been diagnosed since 1992, and never worried about it, fibrosis 0-1, despite 9 mill VL. ALT and AST always top end of normal. But its been so infuriating getting so many denials, denials of appeals, denials by Support Path etc, that I may give it a break for a while and just relax about it, and wait for the market to do its thing.
Why did Support Path deny you?
MG
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Household income (husband and I) income of >$100,000. I'm appealing that with Support Path. It was a blanket denial, even though I submitted our expenses and explained why paying $94,000 would be a financial burden! I asked to speak to a manager, who then told me I could appeal and should submit a letter plus another spreadsheet of expenses. I'm waiting to hear the outcome of that. I asked the manager about a self pay reduced rate option and he said he's never heard of that.
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BDK - Be encouraged! :) I read somewhere on this forum, someone else made more than $100,000, but was approved!
Include as much as you can on your spreadsheet. Take your time, so you don't miss anything.
Blessings,
MG
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Thanks Morning Glory!
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BDK, I was approved by a local Ct insurer without even being required to file an appeal. Moreover, my specialtiy pharmacy informed me, after questioning me why I was so worried about being denied, that theyve seen very few such denials. I know that doesnt comport with what we're hearing, but its what they told me..
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Certain insurers (Anthem, United Healthcare) require you to be F3-4 before approving you for coverage. otherwise they deem treatment "not medically necessary." Then there are some insurers who seem more lenient. Anthem has denied me Sovaldi+ Olysio , and Harvoni (twice), including on appeal. I requested an independent medical review (IMR) on the S/O denial of appeal, and two out of the three GI docs on the IMR panel agreed with the denial. I'm going to try taking the most recent Harvoni denial to an IMR panel also.
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I have similar stats as you do and I was for sure that my insurance will give me issues, but Aetna approved it in a week or so. I have my insurance through my company, but I don't think it makes a difference. You should keep trying as insurance companies are writing up deals with the drug companies every month. Aetna just signed a deal with Gilead the week before I got approved. Good luck!
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Hi new to this site but not hepatitis c. Was diagnosed in 1992 and been non responder twice once to interferon alone and to interferon plus rib. Have had two biopsy one in 1995 and one in 2006 both show minimal inflammation. Just found out about harvoni and made appointment with my Dr. He wants to start me on harvoni and has summited paper work to insurance. My biopsy results do not show any "f" score just some score that starts with K which is 4. I guess odds are slim to none for insurance coverage. My last attempt non response was in 1996. Glad I found this site.
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Hi bdk, What test was done recently to give you the score f1?
Did you have a recent test? A fibrosure test is what they normally give you.
I have united healthcare and was denied first, then my dr did a fibrosure and came back f4, so I got approved. BDK! Don't give up, keep fighting for your right to get treated now!
Sieb, did you have a recent test also? The biopsy in 06 would not be revelant for 2015?
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I will ask doctor today Monday for a blood test like fibrosure or something else to update my profile.
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I had a Fibroscan that showed F0-F1. I'm stil waiting to hear from Support Path (Gilead) re my appeal to their denial for Harvoni, based on income....it takes ages.