Hepatitis Forums

Hepatitis C Main Forums => Hepatitis C Awareness and Activism => Topic started by: OrlandoSun on April 15, 2016, 10:00:09 pm

Title: Insurance Companies Covering more states 2016 , Whats your status?
Post by: OrlandoSun on April 15, 2016, 10:00:09 pm
I have type 1 Geno 1a for about 20-30 years , diagnosed around 2006
waited because treatments seemed worse than the disease.
In October 2014 started trying  to get Harvoni Approval from United Health care .
After a year of denials they reverse there decision on Jan 5th 2016.   
Great huh?   not really  I had already selected a Blue Cross plan on healthcare.gov
because it had better co pays and my wifes DRs in network.   
FloridaBlue won't approve it ,  found out talking to peeps on phone .
Athem, United Health Care and some other insurance companies lifted the F3 restriction that was causing most of the denials,   Great news for many to get approved.  Its not posted anywhere I can find.   One peep that told me this was a  mysupportpath case worker. She told me that Blue cross is approving Hep C infected people without requiring they have stage 3 Fibrosis anymore.   In Louisiana, Massachusetts, Kansas, North Dakota and Oklahoma.  So as of Jan 1rst 2016   many have changed their definition of the term "Medically Necessary" .
If you know for sure what the status is with your State and or Insurance company.
Please post it here and we'll, get a list going.   
Florida Blue is a holdout on the changes, They are stubborn about keeping their money.   It could be that Gilead finally gave some companies discounts or that
the companies realized they are gonna be paying on the class action end later. 
I doubt they just grew a conscience .
My two sense of an update.
Title: Re: Insurance Companies Covering more states 2016 , Whats your status?
Post by: sapphire101 on April 18, 2016, 11:20:07 pm
State/payer/pharmacy list - I like it! Hopefully this information will help someone else work their way through the medical labyrinth.

State California
Anthem Blue Cross with Accredo pharmacy
Paid for my treatment, but only choice was viekira pak for low stage disease.

might be a good idea to put this in our signatures?
Title: Re: Insurance Companies Covering more states 2016 , Whats your status?
Post by: Coach Mike on April 19, 2016, 11:49:43 am
I was the first in Arkansas, according the the specialty pharmacy people, who was approved by Health Advantage and not on the transplant list.  They were amazed I got approved being only F-1.
It was not a quick process. 18 months of constant appeals before I found out I had the right to an independent (external) review.  Everyone has that right under the Affordable Care Act.  Insurance companies don't seem to want their clients to know that fact.
It is really pretty simple:
1. HCV is a potentially life-threatening illness
2. There are very effective cures for this disease
3. Most independent reviews find in favor of the patient
4. Appeal your denials in a timely and proper manner
5. Save every document: doctor's letters, test results, denial letters, list of EHMs and medicines prescribed to treat them-everything.  This is the "evidence" you will need for a successful outcome of your external review
6. Research "extra-hepatic manifestations of HCV" and see how many affect you. The list is extensive: fatigue, dyspepsia, joint and muscle pain, anxiety, insomnia, "brain fog", frequent and persistent infections and so on.

Typically, most insurers take the full allotted time for each denial and appeal.  In my case, that was 30 days.

First prescription: Sovaldi & Olysio (off-label)
1st step-prior authorization-30 days later: denied. Reason: medication not on the formulary.
2nd step-appeal of PA denial-30 days later: denial upheld. Reason: medication not on the formulary
3rd step-final appeal. Same finding as above

2nd Prescription: Harvoni
During this 90 day span, Harvoni was added to my insurer's formulary. So
The same process was followed as above, but this time the denials were based on insufficient level of fibrosis-only F-3 or F-4 qualify for treatment coverage. Another 90 days of fighting

At this point, my original GI said there was nothing more he could do for me.

So, I got an appointment with another GI at the flagship research hospital in the state. Wait time: 8 months. The same process as above, but this GI knew about the external review and wrote a compelling letter to the review board.

Result: Approval. Medication deemed a "medical necessity" by the review committee.

So, get a doctor who knows the process and fight.  You will probably get your medicine within 6 months.

If not, import a quality generic for a $1000 and, at 6 months, you will be SVR 12.
Title: Re: Insurance Companies Covering more states 2016 , Whats your status?
Post by: FutureThinker on April 19, 2016, 12:44:18 pm
I think the choice of one's doctor is just as important as the medicine itself, in as far as getting the drugs approved.  Unknowingly/luckily, I just happened to choose a facility that had a knowledgeable staff re: denial options/IMR right.  I sure didn't know! I drive over an hour to get there, so don't let that get in your way to find competent care. Convenience isn't the  important component here -- getting cured is!

SO -- the moral of this story for those still awaiting treatment:  You need to ask a billion questions, never take "no" for an answer, read everything you can, and if you don't feel you are getting the support and urgency to get this care asap, go find another doctor.  Good ones are out there!! FT
Title: Re: Insurance Companies Covering more states 2016 , Whats your status?
Post by: Luna7 on April 26, 2016, 10:23:02 am
I feel very blessed.
My first pills (Sov/Dak) were taken only 5 weeks after my first Dr. app.
My Dr. said they are approving more claims now.
I have BCBS insurance.
Title: Re: Insurance Companies Covering more states 2016 , Whats your status?
Post by: FutureThinker on April 26, 2016, 12:47:21 pm
Yes Luna, it does appear that the insurance companies are coming around and approving more requests than even last year (thus why I had to go thru a state IMR). I also have BCBS; it seems in some states they are doing better than in others.
Your F score of F2-F3 may have also helped, as F3+ was the criteria BCBS was using for my case.....I'm F1-F2.  But whatever it was, I am thrilled it was quickly approved!! FT
Title: Re: Insurance Companies Covering more states 2016 , Whats your status?
Post by: NYCHEPCMAN on May 18, 2016, 04:08:22 pm
Good news from New York

Under the terms of the agreement, some insurance companies will no longer restrict coverage of some hepatitis C treatments to only those patients with severe symptoms, such as scarred livers. They also agreed to cease denying coverage based on patients' alcohol or drug use and to allow treatment authorized by any appropriately trained provider, not just liver specialists.