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Author Topic: denied twice  (Read 10320 times)

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Offline trapper

  • Member
  • Posts: 56
denied twice
« on: July 29, 2014, 01:27:52 pm »
What do you do after 2 denial..  Is the next step taking ins co to court to get your meds.  I've met all their criteria to get meds (osly/sov) but denied again.  you have to be about dead before they will prescribe meds.  I can wait till new meds come out but whos to say they won't be to expensive.  Ins. co gets paid priemuns every month to provide services which they are not doing very well.  that's bs.   trapper

Offline Dharn55

  • Member
  • Posts: 12
Re: denied twice
« Reply #1 on: July 29, 2014, 02:21:32 pm »
Keep trying and run it up the flag at the carrier. I took it two levels of supervisors. It took about three months but the did approve it. Who is your carrier? Have you looked at their drug formulary to see if these drugs have been added? With my carrier both Sovaldi and Olysio were added recently.

Have you registered with Gilead and J&J? They both have programs to provide assistance if you can't get it covered and will also help with the carriers. Gilead actually told me that if I could not get the a Sovaldi approved they would provide it at no cost. I have heard of others that have gotten both drugs at no cost through the patient assistance programs.

You have to keep at it and not give up. Also check to see who is the pharmacy benefits manager for your carrier and submit appeals to both the carrier and the benefits manager.

Offline iana5252

  • Administrator
  • Member
  • Posts: 187
Re: denied twice
« Reply #2 on: July 29, 2014, 03:22:57 pm »
Gilead Sciences
Drugs covered: Sovaldi (sofosbuvir)
Contact Information: 855-769-7284 or www.MySupportPath.com.
Program Details: Called Support Path, Gilead's program may provide Sovaldi coverage for free to those with a maximum household income of $100,000 for up to a family of three, and 500 percent of federal poverty level for families with four or more members. You can also contact Support Path for assistance finding other sources of health coverage, such as through Medicaid, Medicare or the new health exchanges available through Obamacare.

Johnson & Johnson
Drugs covered: Procrit*, Olysio (simeprevir)
Contact Information: 800-652-6227 or www.jjpaf.org.
Program Details:The Johnson & Johnson Patient Assistance Foundation will provide free coverage of Olysio to those who qualify. The income limit is 500 percent of the federal poverty level, although you can appeal if your income is higher than that. For Procrit, the income cap is 400 percent FPL.
*Procrit is a treatment for anemia—a side effect commonly caused by the drug ribavirin, which is a component of many hepatitis C regimens.

Here's a page with contact info for all pharma programs like the ones Dharn55 mentioned...
http://www.hepmag.com/articles/hepatitis_paps_copays_20506.shtml

Offline lporterrn

  • Member
  • Posts: 1,969
  • LucindaPorterRN
    • LucindaPorterRN
Re: denied twice
« Reply #3 on: July 29, 2014, 09:18:18 pm »
Hi - I will get back to you on this. I have some ideas. Please be patient as I am headed out of town. Hope to have answers by tomorrow, but if not, I''ll post next week. Feel free to message me to remind me if you are feeling forgotten.
Lucinda Porter, RN
1988 Contracted HCV
1997 Interferon nonresponder
2003 PEG + ribavirin responder-relapser
2013 Cured (Harvoni + ribavirin clinical trial)
https://www.hepmag.com/blogger/lucindakporter

Offline Evil Santa

  • Member
  • Posts: 34
Re: denied twice
« Reply #4 on: July 30, 2014, 06:41:12 am »
Hey Trapper, I was denied my 2 insurance appeals also. My medical team submitted all the paperwork to the patient assistance programs. I really didn't have to do it myself so I can't say exactly what you would have to do. I got the Sovaldi and Olysio at no cost to me. But it did take a while. So hang in there it is worth the wait..
Later, Jim

Offline lporterrn

  • Member
  • Posts: 1,969
  • LucindaPorterRN
    • LucindaPorterRN
Re: denied twice
« Reply #5 on: July 30, 2014, 10:48:46 am »
Hi Trapper - Here are links to two different documents that your doctor can use to challenge the denials:
This one is a pdf: http://www.hepmag.com/pdfs/SOF_SMV_NVHR_letter.pdf
This one is a word doc: http://www.hepmag.com/pdfs/SOF_SMV_appeal_letter.docx

If these don't work, I suggest contacting http://nvhr.org/ and letting them know - they may have suggestions. I know they want to know about denials, but so far, they are hearing success stories from people who use these letters.
Lucinda Porter, RN
1988 Contracted HCV
1997 Interferon nonresponder
2003 PEG + ribavirin responder-relapser
2013 Cured (Harvoni + ribavirin clinical trial)
https://www.hepmag.com/blogger/lucindakporter

Offline trapper

  • Member
  • Posts: 56
Re: denied twice
« Reply #6 on: July 31, 2014, 10:36:46 pm »
thanks for the info Jim, Lucinda, Dharn. Iana.  My healthcare is UHC Medicaid.  They carry both meds. Their will issue the drugs if you meet their criteria.  one of   their criteria is Submission of medical records documenting that patient is ineligible for treatment with peginterferon alfa, defined by at least one of the following.  a.  autoimmune hepatitis or autoimmune disorders.  Im ANA positive.  b.Major uncontrolled depressive illness.  c. History of psychosis, schizophrenis, bipolar disorder, schizoaffective disorder, or suicidal  ideation.  D uncontrolled seizures e.  Moderate or severe retinopathy.  f.  Poorly controlled diabetes.  g.  Baseline neutrophil count below 1500/ul. H.  Baseline platelet count below 70,000/ul J Significant ischemic cardiac disease.  K.  Prior intolerance to interferon therapy. L.  Symptomatic hep c induced cryoglobulinemia or reinfection following transplant.  My dr.  put in reasons for ineligibility  to interferon based on platelet count.  My platelet count is 146.  that's why they denied.  they said platelet count has to be below 70,000/ul.  I don't know about the autoimmune disorder.  My ANA was positive.  They also want a signed release from someone other than me they can talk to.  I took paperwork ins co wanted to dr and asked assistant if my dr needed to sign and send back.  She said didn't have to because he's my dr and doesn't need to have permission to talk to them.  On an appeal that's what they want.  So that didn't get done in time.  I wanted to sit down with assistant when she filled out appeal but she wouldn't have it and she screwed it all up.  Im pissed about that.  I'm trying to get into another clinic but it takes so long.  I gave them all my med records so maybe they will do something.  In the meantime I'm trying to get the clinic I'm going to to get it in right.  I've also got a call into an att. who has hcv.  to see what I can do.  this clinic seems to want to get all the patients they can and just wait for other meds to come out.  they seem to not want to fight for anything or anyone.  Ins. co wants me to try other meds first.  that means interferon, sof, and rib.  Im stage 3 w/cirr.  My chances of a cure with interferon is 70%,   sof/sim combo  95% cure rate.  This is a no brainer.  They are saying in order for them to prescribe off-lable meds you have to be almost dead. 
    Lucinda,  I do have a copy of of the NVHR letter that I took up for them to look at,  Dr.  assistant looked at it and gave it back.   Thanks for your time.   Trapper

 


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