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Author Topic: Is insurance the decision maker or pharmacy?  (Read 10709 times)

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Offline BubbaT

  • Member
  • Posts: 267
Is insurance the decision maker or pharmacy?
« on: February 28, 2015, 07:07:40 pm »
i am asking for info on the approval process ?

Can someone tell me who has the final say on whether or not you get approved for treatment?

I have had one denial letter from Caremark !    Why are they the determining factor?

My doctor sent an appeal and I have not heard their decision!

What advice or recourse is available ? 
This must make many people angry about the way the treatment is administered!
I read where many have to go thru this appeal process because the root cause is money.

Thank you for your suggestions, opinions, etc!

I have united healthcare insurance and Caremark is the pharmacy cvs!
I was tested pos in 95 and my latest fibrospect showed f4
Ammonia level was 222 and have acute pain in the left quad
Just started taking Ixifanan. And lactiluose,
Hepc 1a
Logged
Age 57 male
Infected late 70's
Diagnosed 95
1a, 2 prev biopsy 95, 2004
Ct 2007, 2015
Treatment Naive
F4 A3. Fibrosure/ CT 2-5-15. Ammonia 222
VL 2.2 mil.
Started Harvoni  3-3-15. 12weeks, finished 5-26-15
4 week VL undetected
12 week EOT undetected

Offline Lynn K

  • Global Moderator
  • Member
  • Posts: 4,546
  • Get tested, get treated, get cured, fight Hep c!
Re: Is insurance the decision maker or pharmacy?
« Reply #1 on: March 15, 2015, 06:14:49 pm »
First off APPEAL, APPEAL, APPEAL!!!!!

Caremark is more than a provider of drugs more than a pharmacy the provide our meds as well as our prescription drug insurance coverage.

What we as patients do not usually see unless we are having trouble getting meds is that Caremark and others ie Express Scripts are Pharmacy Benefit Manager (PBM) and work to reduce costs for insurers for expensive drugs.

http://en.m.wikipedia.org/wiki/Pharmacy_benefit_management


Also

"Development and management of drug formularies is an integral component in the pharmacy benefit management (PBM) services CVS/caremarkTM provides to health plans and plan sponsors. Formularies have two primary functions: 1) to help the PBM provide pharmacy care which is clinically sound and affordable for plans and their plan members; and 2) to help manage drug spend through the appropriate selection and use of drug therapy"

https://www.caremark.com/portal/asset/FormDevMgmt.pdf

Caremark prior authorization requirements for Harvoni

http://www.caremark.com/portal/asset/FEP_Criteria_Harvoni.pdf

Good luck

Logged
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Is insurance the decision maker or pharmacy?
« Reply #2 on: March 18, 2015, 04:01:39 pm »
If you are F4, then United should be covering you, based on their own clinical management guidelines.  You should appeal (it should tell you how in your denial letter).  If that 1st appeal is denied, then you have the right to appeal again.  If that is denied, you have the right to request an independent medical review.  be sure to meet the deadlines for these appeals.  gather copies of all your tests, lab work, etc to send in when you appeal.  Keep copies of everything and keep a diary of what you send yo whom and when.

If your appeal is denied, you can them contact Gilead Support Path and request aid.  this is based on your household income. if your combined household income is less than $100,000, they will help you considerably.  Good luck.
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Debula

  • Member
  • Posts: 257
  • "Your body hears everything your mind says"
Re: Is insurance the decision maker or pharmacy?
« Reply #3 on: March 18, 2015, 04:39:33 pm »
BDK-Do you have to go through all of the appeals before you can apply to Gilead support path? 
I hate that they make this so damn difficult for us
I have United too but my PBM is OptimRX.   I haven't even been prescribed yet and already I'm stressing about all this stuff
Logged
80's DX: NonA,B
Non responder to Interferon
3/6/2015-GT 1a
VL-1920000 IU/mL
FibroSURE: Fibrosis stage F4 (0.79)
                  Necroinflammat activity A3 Severe (0.75)
AST 88,  ALT 120, Platelets 73
4/16/2015-Started Harvoni (24 weeks)
5/13/2015-4 weeks AST 26, ALT 36 
5/22/2015-5 weeks  VL UND
6/17/2015-9 weeks  VL UND AST 28 ALT 40
7/31/2015-15 weeks VL UND AST 27 ALT 39
9/22 Diagnosed with HCC
10/1-EOT
10/29-SVR4
12/23-SVR12
I AM HEPC FREE! :)

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Is insurance the decision maker or pharmacy?
« Reply #4 on: March 18, 2015, 04:47:18 pm »
Yes, you have to apply for pre-authorization thru your insurance (your doctor writes the prescription and she might send it to a specialty pharmacy who handles it for you, or you take it to your local pharmacy and they send it to the specialty pharmacy.)  If it is denied (based on the insurance's clinical guidelines), then you appeal it.  if that appeal is also denied, then you call up Gilead's support Path (or download the form from their site) to request support.  If your combined household income is >$100,000, they will deny you but you can appeal that.  Some insurance companies (Aetna, Humana) seem to be approving any level of fibrosis.  others (Anthem, UHC) seem to be insisting you are F3 or worse.  But there also seem to be exceptions to everything, hence the need to keep pushing.  Don't be stressed, just be prepared to be patient.  It is such a volatile market, these drugs have only been approved by the FDA for 6 months! There are bound to be changes.  if you are F0 or F1, you probably have time on your side at least for a little while.
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline BubbaT

  • Member
  • Posts: 267
Re: Is insurance the decision maker or pharmacy?
« Reply #5 on: March 19, 2015, 12:47:36 pm »
Thanks bdk,

I'm on week 3 now and fighting this devil/ virus and kicking it's arse!

I appreciate the advice you gave!

We fight together...and win together...
Logged
Age 57 male
Infected late 70's
Diagnosed 95
1a, 2 prev biopsy 95, 2004
Ct 2007, 2015
Treatment Naive
F4 A3. Fibrosure/ CT 2-5-15. Ammonia 222
VL 2.2 mil.
Started Harvoni  3-3-15. 12weeks, finished 5-26-15
4 week VL undetected
12 week EOT undetected
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