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Author Topic: DENIAL LETTER - reason no known history of drug abuse or alcohol  (Read 18512 times)

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Offline sharkie

  • Member
  • Posts: 11
DENIAL LETTER - reason no known history of drug abuse or alcohol
« on: May 12, 2015, 12:44:48 pm »
I recieved my denial letter from OptumRx Harvoni Tab telling me that I was denied because I had no known history of drug or alcohol use.
The reason for that is I moved to florida I used a different gastroenterologist and the information I used was different from what I told my first doctor.
I told him I had a blood transfusion in 1960 which is true,but I also used intravenous drugs,so when my doctor sent the paperwork in that was not on there. I find it hard telling people I was an addict even a doctor.
So now I called my original doctor and asked them to fax a copy that shows the complete history of my drug use.
I don't understand what the difference is,I got hep c somewhere.
Thank's
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Offline Debula

  • Member
  • Posts: 257
  • "Your body hears everything your mind says"
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #1 on: May 12, 2015, 02:33:37 pm »
Wow that sounds crazy
I hope you are able to work this out with them
Good luck!
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 dragonslayer

  • Member
  • Posts: 873
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #2 on: May 12, 2015, 03:03:09 pm »
That's totally whacked..  A prior drug history has never been a prerequisite nor a requirement for insurance coverage..  Ive never seen that on any list of treatment criteria.  Everybody knows that iv drug use is NOT the only way to get this disease.  Something's very amiss here.
Logged
Paul

DX 2008
Started Harvoni 11/26/14 for 8 wks
Completed 8 wks Harvoni 01/20/15
EOT RNA Quant result:  Detected 29
7.5 wk post tx: Detected < LLOQ(12)
11 wk post tx: UNDETECTED SVR12
24 wk post tx: UNDETECTED SVR24; AST 26; ALT 22; ALP 73
48 wk post tx: UNDETECTED SVR48; AST 18; ALT 18; ALP 70
GT 1a
vl 2.4mil
2008 bpx: Stage&Grade 0
2013 bpx: Stage&Grade: 0-1
IL28B: TT
likely infected early '70s

Offline sharkie

  • Member
  • Posts: 11
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #3 on: May 12, 2015, 05:38:29 pm »
Thats what I said,what difference does it make how a person got it.
Been on the phone most of the day trying to get the doctors to fax old medical records to my G doctor.
_____________________________________
This is what it says
Based on the information provided,you do not meet meet the established medication - specific criteria or guidelines for Harvoni Tab 90-400M G at this time
Harvoni is denied for medical necessity.Medication authorization requires the following:
(a) You have no known history of illicit drug abuse or alcohol abuse.
(b) You have no known prior history of illicit drug abuse or alcohol abuse and have abstaind from the use of illicit drugs and alcohol abuse for the past six months.
Reviewed by: DXD,Pharm.D
Logged

Offline FutureThinker

  • Member
  • Posts: 711
  • Onward and upward!
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #4 on: May 12, 2015, 08:00:27 pm »
Sharkie, I can't believe what I just read.  My denial letter last week basically said I wasn't sick enough -- only have stage 2 fibrosis vs. stage 3 or 4 or cirrhosis....... what in the world will they (the insurance "people") come up with NEXT??????

We're all in this with you, take a deep breath and hang in there......
Logged
Treatment naive
Likely contracted mid-70s
Diagnosed 1a, 2011
F1-2
Harvoni X 12 weeks, completed 5/17/16
Pre-treatment: VL 3 mil, AST 64, ALT 84
4 week labs: VL 30, AST 21, ALT 14
8 week labs: VL UD!!!, AST 22, ALT 16
12 week labs: VL UD, AST 23, ALT 14
2 wk EOT: VL UD
12 wk EOT: VL UD, AST 22, ALT 13 =  SVR 12! Yay! 
Last hep appointment: VL UD, AST 19, ALT 12 = SVR 39! I AM DONE!

Offline sharkie

  • Member
  • Posts: 11
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #5 on: May 12, 2015, 09:03:14 pm »
Quote from: FutureThinker on May 12, 2015, 08:00:27 pm
Sharkie, I can't believe what I just read.  My denial letter last week basically said I wasn't sick enough -- only have stage 2 fibrosis vs. stage 3 or 4 or cirrhosis....... what in the world will they (the insurance "people") come up with NEXT??????

We're all in this with you, take a deep breath and hang in there......
I'm still a little in shock,so all I can do is wait and thats the hard part,who know's where I got hep c from,that blood transfusion or not being careful using drugs.
I was thinking about going down to the va if this don't work out for me,but the red tape is unbelievable
Thanks
Logged

Offline okmimi

  • Member
  • Posts: 3
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #6 on: May 12, 2015, 09:46:36 pm »
I have OptumRx and received several denial letters. Made no sense when I read them at the time, but I don't remeber what they said. (I think I trashed them because it made me mad!) Months later, out of the clear blue, I was approved! My co-pay was $100, but my drs office had a coupon so I only pay $5. Be patient. The drs will submit it again.
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Offline sharkie

  • Member
  • Posts: 11
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #7 on: May 12, 2015, 10:00:06 pm »
Quote from: okmimi on May 12, 2015, 09:46:36 pm
I have OptumRx and received several denial letters. Made no sense when I read them at the time, but I don't remeber what they said. (I think I trashed them because it made me mad!) Months later, out of the clear blue, I was approved! My co-pay was $100, but my drs office had a coupon so I only pay $5. Be patient. The drs will submit it again.
I'm confused about OptumRx are they the people that supply the meds because I just went on social security with medicare and have umr as my secondary insurer and I thought they would pay for any medication,appreciate if someone can clear this up..
Thanks
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Offline Lynn K

  • Global Moderator
  • Member
  • Posts: 4,546
  • Get tested, get treated, get cured, fight Hep c!
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #8 on: May 12, 2015, 11:01:24 pm »
Legal-eze I interpret your denial slightly differently:

"Medication authorization requires the following:
(a) You have no known history of illicit drug abuse or alcohol abuse.
(b) You have no known prior history of illicit drug abuse or alcohol abuse and have abstained from the use of illicit drugs and alcohol abuse for the past six months."

In other words to be authorized either

(a) You have no known history of illicit drug abuse or alcohol abuse.(meaning you have never used drugs or abused alcohol or no approval)

or

(b) You have no known prior history of illicit drug abuse or alcohol abuse and have abstained from the use of illicit drugs and alcohol abuse for the past six months. (meaning you have never used drugs or abused alcohol or have abstained form using for at least six months)

So they want clean and sober for at least six months.

If they believe you have previously abused drugs or alcohol they want evidence you are clean for at least 6 months or they won't approve.

To be approved they want no history of drugs or alcohol or abstained for 6 months.

That is what happens when lawyers try to write things just confuses the heck out of people
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 okmimi

  • Member
  • Posts: 3
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #9 on: May 13, 2015, 07:04:46 am »
In response to: "I'm confused about OptumRx are they the people that supply the meds because I just went on social security with medicare and have umr as my secondary insurer and I thought they would pay for any medication,appreciate if someone can clear this up."

All I know about Optum Rx is that they are a pharmacy that fills and mails your drugs to you. I either have Aetna or UHC insurance (can't remember right now) and people I work with who take monthly Rxs use Optum.
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Offline Debula

  • Member
  • Posts: 257
  • "Your body hears everything your mind says"
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #10 on: May 13, 2015, 12:15:12 pm »
Quote from: okmimi on May 13, 2015, 07:04:46 am
In response to: "I'm confused about OptumRx are they the people that supply the meds because I just went on social security with medicare and have umr as my secondary insurer and I thought they would pay for any medication,appreciate if someone can clear this up."

All I know about Optum Rx is that they are a pharmacy that fills and mails your drugs to you. I either have Aetna or UHC insurance (can't remember right now) and people I work with who take monthly Rxs use Optum.

I have OptimRx through UHC and they are not just a pharmacy.  I can't remember what it is called but they are the plans benefit manager as well (whatever that means)   From my understanding the script from your doctor goes to them and their pharmacist reviews it.  They either request more information, deny or approve the medication based on the plan criteria.   I would call the pharmacist or the approval dept and ask what that means exactly
 I got approved right away but my situation is different because I am F4 fibrosis
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 Karen3717

  • Member
  • Posts: 28
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #11 on: May 13, 2015, 09:38:51 pm »
I'm with Lynn regarding the interpretation.  Also, entirely likely that doc office didn't "check a box".  I work in physicians office that deals with prior authorizations for high dollar biologic drugs & we see this type of thing all the time.  These specialty pharmacies (pharmacy benefit managers) will deny in a heartbeat if every i isn't dotted & t crossed.  I believe Optum Rx is your Medicare part D provider.  We sometimes have to submit PAs 2-3 times before success.  The doc office should be on top of these denials.  Last resort is what is called a "peer to peer review" whereby your doc gets on the phone with the doc at the pharmacy benefit company.  They discuss your case detail & then come to decision, hopefully favorable. 
Logged
Transfusion 1982; Multiple accidental needlesticks; healthcare worker
(+) HCV antibody 1991
Genotype 1a
2001-Pegintron/Ribavirin 48 wks. Relapse 2mo post tx
2015-VL 316,000
Fibrosure-F2
Started Harvoni 3/13/15
2 weeks:  HCV PCR <15-DETECTED
4 weeks: HCV PCR <15-DETECTED
8 weeks: HCV PCR <15-DETECTED
12 weeks:  HCV PCR: NOT DETECTED!
4 Weeks EOT: HCV PCR:  NOT DETECTED!
12 Week post TX:  HCV PCR NOT DETECTED!

Offline gregj

  • Member
  • Posts: 7
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #12 on: May 14, 2015, 09:13:04 am »
Hi Folks I tested positive for Hep C last year. After deciding not to use the Interferon treatment I am now on my way to India to find out what the process is for buying the generic Sofosbuvir being manufactured there. I am recording my experiences in a diary published at

www.hepatitisctreatment.homestead.com

 I hope by sharing this experience with you it may help some of you get Sofosbuvir at a much cheaper price than is possible in most western countries (I'm from Australia where the price for a three month treatment is $90,000)
Logged

Offline FutureThinker

  • Member
  • Posts: 711
  • Onward and upward!
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #13 on: May 14, 2015, 01:13:11 pm »
Gregj -- We will all be very interested in your experience in India! Thanks for the link.
Logged
Treatment naive
Likely contracted mid-70s
Diagnosed 1a, 2011
F1-2
Harvoni X 12 weeks, completed 5/17/16
Pre-treatment: VL 3 mil, AST 64, ALT 84
4 week labs: VL 30, AST 21, ALT 14
8 week labs: VL UD!!!, AST 22, ALT 16
12 week labs: VL UD, AST 23, ALT 14
2 wk EOT: VL UD
12 wk EOT: VL UD, AST 22, ALT 13 =  SVR 12! Yay! 
Last hep appointment: VL UD, AST 19, ALT 12 = SVR 39! I AM DONE!

Offline dragonslayer

  • Member
  • Posts: 873
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #14 on: May 14, 2015, 11:23:51 pm »
Gregj.. it's generic Harvoni you want, not generic Sofosbuvir , isnt it?
Logged
Paul

DX 2008
Started Harvoni 11/26/14 for 8 wks
Completed 8 wks Harvoni 01/20/15
EOT RNA Quant result:  Detected 29
7.5 wk post tx: Detected < LLOQ(12)
11 wk post tx: UNDETECTED SVR12
24 wk post tx: UNDETECTED SVR24; AST 26; ALT 22; ALP 73
48 wk post tx: UNDETECTED SVR48; AST 18; ALT 18; ALP 70
GT 1a
vl 2.4mil
2008 bpx: Stage&Grade 0
2013 bpx: Stage&Grade: 0-1
IL28B: TT
likely infected early '70s

Offline morning_glory

  • Member
  • Posts: 104
  • This is the first day, of the rest of your life...
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #15 on: May 15, 2015, 07:57:27 am »
Quote from: sharkie on May 12, 2015, 05:38:29 pm
Thats what I said,what difference does it make how a person got it.
Been on the phone most of the day trying to get the doctors to fax old medical records to my G doctor.
_____________________________________
This is what it says
Based on the information provided,you do not meet meet the established medication - specific criteria or guidelines for Harvoni Tab 90-400M G at this time
Harvoni is denied for medical necessity.Medication authorization requires the following:
(a) You have no known history of illicit drug abuse or alcohol abuse.
(b) You have no known prior history of illicit drug abuse or alcohol abuse and have abstaind from the use of illicit drugs and alcohol abuse for the past six months.

Reviewed by: DXD,Pharm.D


I agree with Lynn, as well!
Lynn, thank you for taking the time to clarifying the wording.  :)
Logged
Likely infected - mid 70's / Diagnosed - mid 90's
Geno type - 1a
AST - 45
ALT - 51
Viral Load - 435,120
Liver Biopsy 6/2004 - F1-2
Fibrosure 5/2011 - F1-2
Fibrosure 2/2014 - F-0
Treatment Naive, prior to Harvoni
Harvoni started on 5/16/15
8-week Treatment Completed (7/10/15)
4-week bloodwork (6/11/15) Undetected, AST 15, ALT 17
8-week bloodwork (7/13/15) Undetected, AST 14, ALT 16

Offline sharkie

  • Member
  • Posts: 11
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #16 on: May 15, 2015, 07:13:42 pm »
Someone called me from my insurance company they told me to call my doctor they said I was approved and the the harvoni tab 90-400 g will be mailed to us,after that my home.Don't no what happen and don't care to ask I am happy just to get a chance to have this medicine.
All these years there was a symbol on my insurance card and I never new what it meant,it was a symbol for OPTUM Rx and it turn out there the one that mail the meds.Don't no if it means anything I just threw it out there.
Thank's for the help on this forum.
Logged

Offline FutureThinker

  • Member
  • Posts: 711
  • Onward and upward!
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #17 on: May 16, 2015, 05:38:00 pm »
Excellent news and hoping this will be the end of this chapter for you!!
Logged
Treatment naive
Likely contracted mid-70s
Diagnosed 1a, 2011
F1-2
Harvoni X 12 weeks, completed 5/17/16
Pre-treatment: VL 3 mil, AST 64, ALT 84
4 week labs: VL 30, AST 21, ALT 14
8 week labs: VL UD!!!, AST 22, ALT 16
12 week labs: VL UD, AST 23, ALT 14
2 wk EOT: VL UD
12 wk EOT: VL UD, AST 22, ALT 13 =  SVR 12! Yay! 
Last hep appointment: VL UD, AST 19, ALT 12 = SVR 39! I AM DONE!

Offline sharkie

  • Member
  • Posts: 11
Re: DENIAL LETTER - reason no known history of drug abuse or alcohol
« Reply #18 on: May 16, 2015, 08:19:35 pm »
Quote from: sharkie on May 15, 2015, 07:13:42 pm
Someone called me from my insurance company they told me to call my doctor they said I was approved and the the harvoni tab 90-400 g will be mailed to us,after that my home.Don't no what happen and don't care to ask I am happy just to get a chance to have this medicine.
All these years there was a symbol on my insurance card and I never new what it meant,it was a symbol for OPTUM Rx and it turn out there the one that mail the meds.Don't no if it means anything I just threw it out there.
Thank's for the help on this forum.

hey thanks 1999 is when I first heard it on the radio about if you have had a blood transfusion before the 70's you should get a hep c test,I had a transfusion in 1957 so I new it didn't look good for me.
I wanted to try the interferon and pegasys but read to many bad things like side affects for one,I did not want to put my young kids threw that,So I waited and waited for something better.
I'm real happy but I am not going to get my hopes up just yet.
Thanks
Sonny S.
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