Author Topic: Insurance Questions (Read 42019 times)

lporterrn · « **on:** September 30, 2014, 06:43:23 pm »

If you are on hep C treatment, I am wondering:
What is your insurance plan?
What state do you live in?
Were you denied insurance prior to approval?

If you were denied hep C treatment and going through the approval process:
What is your insurance plan?
What state do you live in?

Finally, does anyone LOVE their insurance plan, and if so, who do you use, and what state do you live in?

Thanks.
Lucinda

Krissy · « **Reply #1 on:** October 01, 2014, 11:52:38 am »

Hi Lucinda,
I have insurance with United Healthcare and I live in Texas. I had trouble getting my Sovaldi/Riba treatment approved at first. My dr. had prescribed 24 weeks for my Type 3. At first insurance denied because they said the recommended treatment should be for 12 weeks of Sovaldi/Riba plus Interferon.
The Nurse practitioner at my Liver Specialists office went above and beyond to help me get approved. She put together all kinds of recent research data to show that the insurance was basing their decision on old data. She repealed 3 times and she finally called them and used some veiled threats to get them to finally approve the S/R treatment. It took about 2 months.
Having said that, I must say that in all other ways United Healthcare has been a great insurance company. They have great doctors and hospitals in network and have paid all of my family's claims with no issues. And we have had claims in the millions! My husband had pancreatic cancer 2 years ago and they paid for everything. 10 years ago he had a heart valve replaced and they paid for everything. No hassles. Now they are paying for my treatment and it only costs me $85 per month for the meds . I am very thankful and would definitely recommend them.
I am so grateful that we have excellent insurance. It has literally been a life saver.
Krissy

techson · « **Reply #2 on:** October 01, 2014, 01:00:27 pm »

I have lived with Hepatitis C since 1998.
I have waited 17 years for a cure to be found and health insurance to become affordable. this year I rejoiced that both prayers had been answered. I have spent the better part of this year being retested, blood work, liver biopsy, and was told by my doctor (GI) that the new drug Sovaldi/Olysio Combo Cures 94% of patients with my disease. He has treated 10 other patients with this combo. these drugs are listed by my insurance company (blu cros blu shld texas) as tier 3 drugs requiring prior approval. bcbstx has denied the claim and the first appeal. I was told by the nurse at the specialty pharmacy that the denial was because my biopsy showed only stage f1 fibrosis and to meet guide lines I must have stage f3 fibrosis or higher. I am appalled that the reason is not that the treatment might be ineffective but that I'm not sick enough. I was very happy when the biopsy results came back f1, and patting myself on the back over how well I've taken care of myself sine being diagnosed in 1998 with a disease known to shorten lifespans by 23 years or more. this disease is killing me, they have a cure, and I wont qualify for treatment until I'm sicker because the cost of the medication is prohibitive.

lporterrn · « **Reply #3 on:** October 01, 2014, 01:10:28 pm »

Thank you for your story - we are fighting to change this. One thing I am hoping is that they will approve Harvoni (Sovaldi plus ledipasvir) which should be approved in less than 10 days. Please let me know.

Krissy · « **Reply #4 on:** October 01, 2014, 02:06:10 pm »

Techson ,
I sincerely hope that you can get treatment covered and can finally get cured. Keep fighting and ask your health care team to help you. Keep calling and bugging them until you get what you need. I called my insurance myself numerous times too. I asked them for documentation on every decision they made. It pays to be your own advocate as well.
Try to see if you can get the pharmaceutical companies to assist as well if you haven't tried this already.
Best wishes for a healthy future.
Krissy

Evil Santa · « **Reply #5 on:** October 01, 2014, 02:07:05 pm »

I live in Minnesota
Blue Cross Blue Shield
Denied S/O and the appeal denied for off label prescribing.
Health care team (Duluth Clinic Duluth Mn) did all the work to get drug companies to pick up the tab. Cost me nothing.
Started 12 week treatment June 13 2014. Undetectable at 4, 8, 12 weeks.
We have been very happy with our insurance. We are both early retired and insurance part of wife's retirement package. And have never had any problems. I used to also have Blue Cross from my job when I was working..
Jim

Evil Santa · « **Reply #6 on:** October 01, 2014, 02:10:49 pm »

Oh yeah, treated in 2000 with Interferon and Ribaviron non responder. Same insurance they paid..
Jim

Tess1971 · « **Reply #7 on:** October 01, 2014, 05:11:26 pm »

I have Blue Cross Blue Shield of Tennessee (FEHB) and has not trouble at all getting approved. Only requirement was viral load and genotype. I pay $50 copay for 30 day supply and after 3 mos only $55 for 90 day supply. However, I am doing sovaldi and ribavirin. Dr said doing the other combo that you called Harvoni would be considered two specialty drugs and be the problem with the insurances. And if the other was done off label they would not cover.

techson · « **Reply #8 on:** October 01, 2014, 06:11:35 pm »

update

I am a middle-age white male GenoType 1a viral count was a little over 6m per ml

denial letter I received today states

the attending provider has not demonstrated that this patient is interferon intolerant as demonstrated by one or more of the following

-intolerance to IFN
-Autoimmune hepatitis and other autoimmune disorders
-Hypersensitivity to PEG or any of it's components
-Decompensated hepatic disease
-Major uncontrolled depressive illness
-A baseline neutrolphil count below 1500/μL a baseline platelet count below 90,000/μL or baseline hemoglobin below 10 g/dL
-A history of preexisting cardiac disease

Using a non FDA approved interferon free regimen should be considered ONLY in those patients who require immediate treatment, because it is anticipated that safer and more effective (FDA approved) interferon-free regimens will be available by 2015. The AASLD-IDSA guidelines recommend that in many instances, it may be advisable to delay treatment for some patients with documented early fibrosis stage (F 0-2), because waiting for future highly effective, pangenotypic, DAA combinations in IFN-free regimens may be prudent

this is from blu cros blu shld tex silver hmo plan (Obama care)

my concern is that prior to now, I have been unable to afford healthcare (with preexisting hcv condition). they want to put the whole thing off till after mid term elections which they are hoping will change the senate and be able to repeal obamacare or at least subsidies which are as I understand it a very dicy situation.

Nurse sent the prescription to a specialty pharmacy that is out of network for my hmo. they automatically filed (wasted) my first appeal. If I hadn't called today they would have eventually wasted the second internal (final) appeal and I would be already looking at an independent review as last resort.

I live in a rural area where I was lucky to get an in network referral to a GI. no hematologist exist in this area but I may have to travel to get this sorted out.

this whole process has become so politically polarizing and I'm scared if I don't get this treatment now I might not ever get the chance.

I have young kids and a stay at home wife who all depend on me to bring home the bacon, pay the mortgage and keep the lights on.

it's especially frustrating when I Google harvoni, all I get is investor news for those that are looking to increase their wealth

Tess1971 · « **Reply #9 on:** October 01, 2014, 10:03:48 pm »

Being type 2b was a requirement for me to get approved for the interferon free treatment.

lporterrn · « **Reply #10 on:** October 02, 2014, 12:10:07 am »

Hi Techson,
Harvoni isn't expected to be approved until Oct 10, so you won't get it approved until then. (And it may take a few weeks before everyone is up to speed) I hope your doc will resubmit. Also, Gilead will help you and your doctor through the approval process.

techson · « **Reply #11 on:** October 02, 2014, 11:01:16 am »

Quote from: lporterrn on October 01, 2014, 01:10:28 pm

Thank you for your story - we are fighting to change this. One thing I am hoping is that they will approve Harvoni (Sovaldi plus ledipasvir) which should be approved in less than 10 days. Please let me know.

Do you know what the American version (Brand Name) of this drug will be called?
Harvoni is the European brand name as I understand it.

can you provide any links (url) about this

diamondd · « **Reply #12 on:** October 02, 2014, 12:23:21 pm »

I need to deal with choosing a Medicare Part D insurer. I've been on SSDI since 2005, and Medicare A & B since April 2007. However, signing up for Part D has not made sense in a cost-benefit analysis (just use an Rx discount card)...until now. I've been waiting for Harvoni (1b, stage 4 cirrhotic, compensated liver, 11,000,000 viral load). Before Gilead will consider any charitable assistance, I was told I have to sign up for Part D. Being 63, I will have to pay a significant penalty premium, since I didn't sign up when original Medicare kicked in. So, which company, which Part D plan should I choose? Money is a definite consideration, as SSDI is my only source of income, and I have no tangible assets. I see my liver dr. on 10/28 and hope to get the scrip for Harvoni then.

I live in AZ. Suggestions?

lporterrn · « **Reply #13 on:** October 02, 2014, 01:32:57 pm »

Teschson - Although Harvoni is the European name for sofosbuvir/ledipasvir, we think it will have the same name. No official name yet, so no link

Tess1971 · « **Reply #14 on:** October 02, 2014, 03:06:21 pm »

Oh, I did know about sofosbuvir and ledispasvir as it is what I requested of my dr to take in the first place, just did not know the name Harvoni and that it was what was being to referred to on forum as new one coming. I was told that the ledispasivir would have to be prescribed offlable at that time and would come out of pocket since insurance would not go along. He also felt that when it comes out it will be another $$ ballgame coming down the pike and insurance cos are going to find a way for us to pay more out of pocket if becomes the norm. I am already seeing some changes coming down the pike in insurance companies for 2015 due to the sovaldi pricing. Scarry stuff how they maneuver definitions and classifications of drugs to suit them.

DesertGuy · « **Reply #15 on:** October 02, 2014, 07:06:47 pm »

Yes and I was told yesterday by the Dr. that my insurance may not want to pay for a second super drug treatment. I hope the ledispasiver treatment is only one pill a month at $1000 a piece-- LOL.

Tess1971 · « **Reply #16 on:** October 02, 2014, 07:57:01 pm »

That is another reason I made sure I did this treatment in the 2014 calendar year because how it was classified and covered was already locked in for the year because it was approved end of 2013. Now 2015 after the surge of people taking advantage of it I already saw some changes in the open season where they have added another Tier classification for specialty drugs. I have not checked out the details yet, but, I have learned in the past that things I used to pay a co-pay for I now pay a percentage of adjusted cost. And my insurance is by no means cheap.

Mike · « **Reply #17 on:** October 03, 2014, 04:13:59 pm »

One of the factors insurers consider when approving Hep-C treatment is that 80% of those with chronic infections don't develop symptoms, don't have any progression and don't have liver damage. 20% will have some symptoms and liver disease, while 5% will have significant symptoms and liver damage.

There are approximately 3.1 million chronic Hep-C infections in the US. This means that 2.6 million of those infected don't have any medical issues caused by the infection and most likely, don't need to be treated.

Because of the cost of Hep-C treatment can exceed $120,000.00, and the aforementioned statistics, it is clear why insures are balking, and requiring specific medical documentation prior to approval.

Is this fair? I don't know, as I feel everyone should be treated to help eradicate Hep-C. On the other hand, I understand the economics of Hep-C treatment.

Mike

lporterrn · « **Reply #18 on:** October 03, 2014, 06:36:13 pm »

Mike - these are good questions, and although I am sympathetic to the insurers budget problems, here is what I wrote on the issue: http://www.lucindaporterrn.com/blog/
Bottom line is that waiting until people have stage 3/4 disease is way too late.

Mike · « **Reply #19 on:** October 04, 2014, 12:22:17 pm »

Hi Lucinda,

I agree with the main thrust of the blog post, however, the issue in allocating scarce medical dollars is complicated.

First, when balancing the high cost of Hep-C treatment, compliance with the treatment protocol is critical.

Active drug use is a know factor in treatment compliance, and statistically, active users are less likely to adhere to strict treatment protocols i.e.,taking medication as prescribed, attending medical appointments, following up with lab work and so on.

Knowing that treatment compliance is a critical component for successful treatment outcomes, one can see why this would be a consideration in third-party approval and payment of a expensive treatment protocol.

Asking for a 3-6 month period of sobriety is not necessarily unreasonable, unless there is an immediate need for treatment.

This can be complicated, however, when considering the difficulties with treating addiction;and there should be some type of balance between the two (treatment approval contingent on sobriety).

For instance, medical marijuana is legal in numerous states and is known to be beneficial in managing the residual effects of a variety of diseases/syndromes/disorders, including Hep-C.

Should a patient be denied Hep-C treatment if he or she uses marijuana to manage chronic low back pain or MS? I would say no.

On the other hand, should treatment be denied for an individual who is currently injecting 3 grams of heroin on a daily basis? In this examble, would requiring a period of sobriety for the heroin addict be unreasonable? Maybe. Maybe not.

The point is: these questions can be challenging and don't lend themselves to clear answers.

The sad fact is that, until the cost of Hep-C treatment is significantly reduced, the medical community and medical ethicist will be struggle for the answers -especially when deciding how best to spend scarce medical dollars.

Mike

lporterrn · « **Reply #20 on:** October 04, 2014, 04:00:08 pm »

And here folks is why I love this forum. Mike and I don't agree on this, but we agree on the important stuff- helping others through treatment. Thanks for this point-counterpoint opportunity and all you bring to the forum.

Tess1971 · « **Reply #21 on:** October 04, 2014, 04:06:07 pm »

Ledispasvir (however spelt) has to be taken with sovaldi now and newer versions will be one pill that is a combo of the drugs and I am sure will be quite expensive both being newer specialty drugs. $$ I do not see any of the treatments getting cheaper until they are generics. As long as there is a market at these prices why would it change.

Bucky · « **Reply #22 on:** October 05, 2014, 11:31:40 am »

Mike posted: "Active drug use is a know factor in treatment compliance, and statistically, active users are less likely to adhere to strict treatment protocols i.e.,taking medication as prescribed, attending medical appointments, following up with lab work and so on."
My question is, so drug use in itself doesn't cause the treatment to be less effective but the rejections because of a positive drug screen are completely related to perceived adherence? I have several friends who have C but use MM for other related conditions and have not sought treatment for this reason. I think that the Insurance companies are using this as a way to delay or not pay at all.
I have BCBS of NC and did not have to do a substance abuse test/screening of any kind. My IDS already knew that my only alcohol consumption is two shots of Tequila on my birthday and at New Years. She also knows that I haven't smoked any marijuana in years because of our policies at work. I could not risk loosing my pension & insurance package over smoking the wacky weed.
I was promptly approved for S&O treatment but my liver is pretty beat up. My IDS assured me that I would be approve for Harvoni if the dragon returns in the future. I have a feeling that she is going to be gathering data on S&O failures and retreating/success of Harvoni since she is involved with clinical trials. Hopefully this won't involve me!
Bucky

Willie G, You were correct ..... I had to visit and see what was going on!

Mike · « **Reply #23 on:** October 06, 2014, 12:23:17 pm »

I might need to clarify a bit:

When I say active drug use, I mean it as a catch all phrase. This would include methamphetamine (meth) PCP, barbiturates, crack, huffing, heroin, and so on.

This would also include poly-substance abuse (being addicted to, and abusing more than one substance).

Given the due process rights associated with treatment denials, you can be assured that insures have obtained legal advise/counsel and consent, which supports this type of policy.

The point is, whether right or wrong, some insurers (and state exchanges) are requiring a period of sobriety prior to treatment approval.

Unfortunately, this is a current issue that may arise in the approval process.

Best wishes, Mike

hlthy8 · « **Reply #24 on:** October 06, 2014, 02:07:31 pm »

Hi Lucinda,
I live in California. I was denied twice by Anthem blue Cross and once by Health Net. I was on a PPO for both. I was denied on appeal because I was not sick enough - my Metavir score is 2 not 3. However, I have cryoglobulemia which causes alot of join pain and I am post menopausal so I pursued.
I finally qualified for a patient assistance program and on the Olysio/Sovaldi combo now.

hlthy8 · « **Reply #25 on:** October 06, 2014, 02:10:08 pm »

I should add that I was applying for the off label combo Olysio/Sovaldi because I was a prior non responder to interferon / riboviron. I also had to get the genotype varient test done. But even with all that I was still denied.

lporterrn · « **Reply #26 on:** October 07, 2014, 09:39:00 am »

Hlty8 - I am soooo glad you prevailed. Hope your cryo is helped by treatment.

bsmith9876 · « **Reply #27 on:** October 08, 2014, 06:54:37 pm »

Hi everyone, I have an insurance question, I'm back to the Gastro Nov 5 to start the treatment ball rolling. My company is switching insurance carries Jan 1.

I'd like to get your opinions on whether to get things rolling with my current insurance or wait until Jan.

Mike · « **Reply #28 on:** October 08, 2014, 07:14:44 pm »

A couple points: Your current insurer most likely knows your company is switching to a new insurance provider. If not, they will know by November 1st.

Given the cost and length of treatment, it is doubtful the current insurer will approve the treatment (actually, insurers don't approve treatment. They either approve payment for the treatment or deny).

If the current insurer has way out of paying a $100,000.00+ claim, they will find the loophole.

Knowing this, I would not be surprised if a denial is issued for the Hep-C treatment.

Still, I would start the process now, as there are a lot of things that need to be done prior to treatment (i.e., blood work, liver function tests and so on). The current insurer, in general, will have to approve the diagnostic/liver function tests.

Best wishes, Mike

bsmith9876 · « **Reply #29 on:** October 09, 2014, 08:45:27 am »

Thanks for the reply, Mike. This is the final stage of treatment, actually ordering the drugs. My appt is Nov 5; we were waiting for Sofi/Led to be approved. I've completed all tests, ultrasound, etc.

My doc wants to start the drug request even though I told him about the insurance issue. He was not as concerned as I was. I agree with your opinion. Why would the insurance company pay if they new they were out in Jan?

Oh well. wish me luck. If I get the drugs before the end of the year, how would that work having the new ins. company continue the script?

TYVM, Brenda

Bucky · « **Reply #30 on:** October 09, 2014, 11:08:38 am »

Brenda, I would wait until you change insurance companies if you can.
Here Is my story: I stopped working the first of June but I was still being covered by my employer's insurance because I was burning time until the end of June. Since I wasn't working I started S&O the first of June. Because I retired from state government with a pension & insurance package, the end of June I was switched to the retirement insurance plan and I freaked because I didn't know if my meds would be discontinued.
Luckily, I had chosen the same level of coverage 80/20, and kept BCBS of NC. The Specialty Pharmacy spent about a week getting my order transferred to my new retirement policy without a disruption in my treatment. I don't know what would have happened if I went with one of the other insurance policies that was offered.
Bucky

bsmith9876 · « **Reply #31 on:** October 09, 2014, 11:34:45 am »

Thanks, Bucky. It's a scary thought to think you might have a disruption in treatement. I'll talk that over with my doc on Nov 5.

TYVM

Bucky · « **Reply #32 on:** October 09, 2014, 12:04:06 pm »

My near debacle with the insurance changing had not even entered my mind when I started treatment. I was just so damn happy to have been approved.
In the end, all went well and I hope you get it all straightened out before you start. I would just be careful as we know most insurance companies are putting up a fight to pay for these meds.

Barney · « **Reply #33 on:** October 09, 2014, 04:24:38 pm »

I just realized there's a duplicate of this thread but this one is getting most of the action :-)

Denied twice by UnitedHealthCare for Sovaldi/Olysio. Now I have to request an external review. Employer/carrier in Illinois, work/live in oregon.

Since my original response things have changed:

UHC has a patient advocate who is trying to set up a peer-to-peer review with my doc and one from UHC. Seems like that would have been a good starting place.
I'm sitting here now at the hospital waiting for an endoscopy to determine the source of upper GI bleeding. Last time (May) it was due to portal hypertension from cirrhosis caused by hep c. IMHO killing the virus will go a long way toward giving my liver a break.
tomorrow is the day the FDA should rule on Harvoni :-) One would hope the single-manufacturer version might cost less than Sovaldi/Olysio combo.

It saddens me to know that others are experiencing similar or greater challenges but it's good to know that others can relate!

Barney

rainbowray · « **Reply #34 on:** October 09, 2014, 04:42:10 pm »

Hi Lucinda,
My Insurance is BlueShield EPO in California.
I got approved pretty quick once my labs were in order for the insurance.
At month 5 the insurance asked again for pre-authorization from the Dr. to continue
the treatment and it got the ok in one day. All my ducketts were in order and I called the Dr. Office and BlueShied, and then the pharmacy to make sure all went thru.
I have insurance thru my company I work for. It is working out good.

lporterrn · « **Reply #35 on:** October 09, 2014, 04:53:55 pm »

Thanks everyone - this is very helpful!

johnsshutts · « **Reply #36 on:** October 11, 2014, 11:48:14 am »

I have GEHA with the federal government, in Texas. I will only have to pay a $5 copay for Haroni for 12 weeks. I got the copay card from the Gilead Harvoni website. http://www.mysupportpath.com/. My appt. is on the 28th, will start real soon. Geno 1a, 7 million viral load. Did peg and copeg over 10 years ago. I will be cured!

Tess1971 · « **Reply #37 on:** October 11, 2014, 09:31:51 pm »

wow that's great! I thought you could only qualify for that if you did not have insurance and could not pay. That is really great! good luck.

johnsshutts · « **Reply #38 on:** October 12, 2014, 04:33:34 am »

The copay card covers my copay. I would have had to pay $250 evey 30 days, $750 total. Now I will pay $5 X 3 months, $15 total. I have used these copay cards before. They sure do save you a lot of money. I can't wait to start my treatment!

Tess1971 · « **Reply #39 on:** October 12, 2014, 01:51:09 pm »

Sounds good to me. I pay $50 every 30 days and if had to go longer than 3 months I would pay $55 for 90 day supply, but, fortunately I only have to do 12 weeks.

johnsshutts · « **Reply #40 on:** October 13, 2014, 04:05:39 am »

Did you ger the co-pay coupon? http://www.mysupportpath.com/

Tess1971 · « **Reply #41 on:** October 16, 2014, 11:57:43 am »

No, that copay amount is from my insurance benefit. Thought coupon was only for people that could not afford or had no insurance.

lporterrn · « **Reply #42 on:** October 16, 2014, 12:44:07 pm »

DiamondD - I just saw your post - I suggest you contact an insurance broker in Arizona. Ask for recommendations. They should not charge $ - they get their $ via insurance kickbacks.

diamondd · « **Reply #43 on:** October 16, 2014, 12:54:28 pm »

Thanks, Lucinda.
I already contacted the local Senior Resource Center, who found a Part D plan that will provide all the other medications that I take for $0 copay, and has a monthly premium that is less expensive than the current price I pay for those medications (even with the premium penalty).
However, I see the liver dr. on the 28th (and will hopefully get the scrip for Harvoni then), and the Part D won't go into effect until Jan. 1. There's no way of telling if Harvoni will be on its formulary, and how much it will cost.
My concern is a problem with 12 weeks of continuous treatment.
Since I'm stage 4 cirrhotic, compensated, with esophageal varices and portal hypertensive gastropathy, I am anxious to start treatment. I don't want to slip into decompensated.

lporterrn · « **Reply #44 on:** October 16, 2014, 01:02:52 pm »

Good job Diamondd - your medical condition gives you top priority. I am not 100% sure, but since Medicare covered Sovaldi I believe they will cover this, and by extension, the part D plans must.

diamondd · « **Reply #45 on:** October 16, 2014, 01:08:54 pm »

I will have to rely on charitable assistance if I start treatment before Jan. 1. Then the insurance will kick in, but I'm sure my copay with Harvoni will be too expensive...so it's a question of continuous assistance through all 12 weeks.

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