pissed off

[trapper]

hi im new to this forum but I may need some advice.    I was diag. with hep c g1 on 4/22/14.  GI dr put in for sim/sof.  combo   was denied by UHC because non FDA approved for combo.  Wallgreens called 5/05 and said no pre-auth. for drugs. called GI office and let them know.  They said combo was denied by healthcare provider.  had GI app on 5/21 to discuss other options.  I had been reading info on internet and told dr they were approving combo if you couldn't wait.  criteria for that was inferion intolerant,  high viral load, cirr, or fib. score of f3-f4.  he said they got all that stuff and no approval.  I've been putting together some stuff to appeal it myself and wanted a letter of denial from dr . His sec.  sent a message back saying they have no letter of denial.  She said they did not get prior auth because they know it will be denied.  I asked why would you put in for drugs when you know they will be denied? She had no answer.  She said she would put in for drugs if I wanted but that would be denied.  I said do it but you have to do it right or it will be denied and showed her  printouts off internet, sample appeal letter.  she just looked and gave them back and said they go to meeting all the time on this stuff. Does anybody know what maybe going on? I have hcv geno type 1, fibrospect 2 score  2:4,  ct scan showed cirr., enlarged spleen, viral load  23 mill.  Is this enough to get the drugs sim/sof approved for ins.  Then I think I will have to deal with Medicaid on approval.  thanks for any info.  trapper

[Kel]

I have UHC (RX thru OptumRX), and I was told this today and I am not sure if it will help your situation or not.
1. My doctor submitted RX to specialty pharmacy. They called me and I had to call OptumRX and create an account, since Solvadi and Olysio are tier 2 and tier 3 (specialty drugs) and that they will need a prior and/or letter of medical necessity for the prescribing of these drugs (why they are needed) submitted to UHC by the doctor. I had the specialty pharmacy submit the rx to OptumRX.
2. Called the doctors office and spoke with the benefits coordinator, nurse and office manager in a conference call and told them what insurance told me.
3. Gave them the information to also sign me up for co-pay assistance through PAF and the drug distributors of Solvadi and Olysio so as soon as they get the UHC denial letter they can start the appeal.

www.copays.org/

http://www.patientadvocate.org/patient_services.php?p=751

I hope that this will help you. Sorry you're having this aggravation.

Kel

[trapper]

thanks kal    this gi speciality place don't seem to do anything to help their clients get approved.  I asked my primary dr to get me somewhere else.  he put in a request but haven't heard from them yet..thats been a month.  I've heard that they deny you the first time.  At least I can get an appeal ready.  thanks

[Kel]

Trapper,

My first GIs, while a seemingly very capable physician, staff were just a comedy of errors. So, I found a GI specialist through my insurance and research on Google that seemed to fit my needs which were/are I don't want to have to do all the "leg work", communication, and dedication to helping patients get better or have a better quality of life and I actually called and emailed a few doctors offices. It's my life and health and I don't want to leave it all up to chance or have anyone monkeying around with it - this was my thought process. I hope that you find someone who will work with you or maybe talk directly to your doctor about his staff. K

[Evil Santa]

Sorry to hear. That makes me so thankful for the team that I had working for me. I was treated in 1999. I started with one Doc and ended up switching Doctors and clinics because he was such a jerk. And I am so glad I did.   It is basically the same team of folks there that treated me then. I did not respond to the Interferon and Ribaviron.   The doc told me in 2005 when i asked about Peg Interferon came out to wait for the new drugs. Fortunately my liver cooperated and I had the time to wait.
They have done everything as far as the insurance denial. The 2 appeals, right up to getting the pharmaceutical companies to give me a free ride. I haven't had to do anything but sign a few papers and they did the rest. I am a week into my 12 week course of Sovaldi - Olysio.  I guess all i can say is not all GI docs and departments are created equal. It is your life and health. Do some research and find out who is the best in your area. I guess I was just lucky I ended up with the folks I did. But I was not afraid to switch when I was not being treated as I thought I should be.
I wish you all the best in your battle and hope it all turns out.
Jim

[jberlin]

At the core of this is the cost of treatment. 1st, it should not be so high in the USA, with the same drugs costing much less in other countries, but the cost analysis is also short-sighted, because even at $70,000 it is a bargain versus a liver transplant or worse.  Gillead, maker of Solvaldi, sold $2.3 billion of it in the 1st quarter of 2014.  So, once again medicine is focused on profits and not outcomes, of both insurance companies and drug companies.

You need to find a medical practice that will support you to get the proper treatment and get you cured. If the MDs put in the effort they can get you approved.

I feel stupid saying this, but find a way to get treated and cured! 

Good luck,
jack