Insurance plans

[lporterrn]

For those who are considering changing their insurance plans during open enrollment, this is the best news I've seen: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Ox_MPUB_Future_Pharmacy/PA_Notification_Harvoni_101414.pdf Naturally, you will need to confirm this, but bless United Healthcare for this!

[Surf Till U Die]

    I hope that its true I don't have United but hope BCBS FL has same protocol. I am  waiting to here back on my approval should be any day now. 

     Surfed yesterday Not today     Surfer John

[GSTEPHEN]

I am looking at changing my Medicare part D plan and have been looking for some advise on the coverage for Harvoni. Medicare has not been that helpful with such advice. I completed the Savoldi, peg, rib, combo treatment last march and it did not work. I also have cirrhosis (mild). Just wondering about the whole medicare thing as far as coverage goes and if there will be financial assistance like there was with the Savoldi. I retired on July 1 and had to go onto medicare June 1st so my BCBS insurance stopped and medicare took over. Now I am dealing with the Gap or Donut Whole as it is called. Any ideas?

GS

[diannastarr]

GS, Did you see Lucinda's blog "Tips for Navigating Insurance Prior Authorizations for Hepatitis C Treatment?"

http://blogs.hepmag.com/lucindakporter/2014/10/harvoni_tips_for_navigating_insurance_prior_authorizations_for_hepatitis_c_treatment.html

Hope it helps.

[lporterrn]

GStephan - You didn't say what state you live in, but the best way to do this is to talk to an insurance broker (these are free - they get paid by the insurance company) or use Medicare's online assistance program. After you get recommendations, you can contact the insurance companies and request a link to their drug formularies. Keep in mind that your single biggest ally is http://www.mysupportpath.com/ (you can even call them first to ask if they have info on Medicare plans). Even people who are denied insurance payment of Harvoni are getting the drug for free or nearly free from My Support Path.

[lporterrn]

More info on plans. United Healthcare is now NOT covering Harvoni unless at stage 3 or 4
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Pharmacy%20Resources/Harvoni_Medical_Necessity.PDF

Kaiser is also holding off.

Aetna looks fabulous:
http://www.aetna.com/products/rxnonmedicare/data/2014/GI/hepatitis_c.html

[Bucky]

I love this from the United Healthcare site:

**
Positive urine drug screen findings will not necessarily
disqualify the member for authorization if they
can be explained by the finding of a legitimate prescription for medication that would result in a positive
test (i.e., methylphenidate causing positive findings
 for amphetamines, hydrocodone causing positive
findings for opiates, etc.). A urine drug screen testing positive for cannabinoids will not disqualify
authorization if there is a contemporaneous prescription
 for Marinol, or if the physician attests to
prescribing medical marijuana in states where legal, or
in states where the recreational use of marijuana
has been legalized

Well there you go for the ones who live in the progressive states.
Bucky

[lporterrn]

What really rankles me is that the insurance company pays for treatment bases on their misreading of the AASLD guidelines, BUT they ignore the fact that AASLD gave active drug users a high treatment priority. Hmmm

[Bucky]

What really rankles me is that the insurance company pays for treatment bases on their misreading of the AASLD guidelines, BUT they ignore the fact that AASLD gave active drug users a high treatment priority. Hmmm

Who is going to be our Larry Kramer?
Bucky

[Barbs]

Want to get really rankled?  I'm going to protect this person's identity for now,  but it's a response to an article written by David Heitz called "Harvoni takes the sting out of Hepatitis C treatment" on Healthline.com {{wink}}.

"I work for a managed Medicaid company and I can tell you that this article misses some key points!

Let me start by saying that my company is not run by bean counters! In fact, I've never seen so many liberal, pro-universal healthcare people under one roof in my life! It is beat into your head from day one that our members are our first priority! We have even expanded our services beyond the Medicaid charter!

One of the doctors in this article referred to the insurance side of things as being "just a cost issue." That is a gross oversimplification! If we approved every single request for Hep C treatment, we would be bankrupt in short order! We have no choice but to develop criteria for approving or denying payment for these therapies!

Our criteria are created via a review of current guidelines and best practices, a review of package inserts and approved indications, and a pooling of professional experiences of the physicians and clinical pharmacists that sit on our committees!

After 14 years working in pharmacy, I can tell you first hand that the argument that "physician knows best" is fallacious at best! The same patient could be seen by five different doctors and be given five different opinions and have five different courses of action recommended! Doctors, as a general rule prescribe the newest most expensive therapy available regardless of diagnosis or prognosis! Occasional heartburn that can easily and affordably treated with generic Zantac, will be treated with $300/month Nexium! Barely elevated blood pressure will we treated with $300/month Benicar instead of $4 lisinopril! Every patient needs $700/month adjunct Abilify therapy when they aren't even taking their generic antidepressants regularly! Etc, etc, etc!

Hep C treatment is no different! Many patients can live relatively symptom free for years and have no liver fibrosis/cirrhosis, and others will progress rapidly! I know physicians that want to treat every patient immediately and I know physicians that practice watchful waiting.

We also get plenty of requests for patients that are openly and actively drinking and or shooting IV drugs! Do you think that we should approve $100k in medication for someone that refuses to quit drinking?!

We simply must prioritize the authorizations of these treatments or go bankrupt! It's that simple and let's not forget that the pharmaceutical companies have patient assistant programs!"

[Bucky]

Hello Barbs and welcome,
Would you please tell who wrote that. I would like to know who compared HEPC to heartburn.
Bucky

[Barbs]

Thank you Bucky for the welcome.
Here you go - to the comment section... And, if you decide to comment there, let me know!

http://www.healthline.com/health-news/harvoni-takes-sting-out-of-hepatitis-c-treatment-102614#3

[Lynn K]

Well it looks like I qualify for Harvoni GT 1a, Child A cirrhosis on biopsy Jan 2008, 3 time null responder, interferon (1X) and interferon ribavirin (2X). Just worried about being a Sovaldi Olysio relapse looks OK on the United. But this comment on Aetna "Note: There are no treatment guidelines or FDA-approved therapies for retreatment after failure of a sofosbuvir-containing regimen." has me a little concerned.

Of course none of these are my insurance which is BCBS Express Scripts through my employer. I see my hepatologist on Monday guess I will go from there.

Good luck to all,
Lynn

[Bucky]

Well it looks like I qualify for Harvoni GT 1a, Child A cirrhosis on biopsy Jan 2008, 3 time null responder, interferon (1X) and interferon ribavirin (2X). Just worried about being a Sovaldi Olysio relapse looks OK on the United. But this comment on Aetna "Note: There are no treatment guidelines or FDA-approved therapies for retreatment after failure of a sofosbuvir-containing regimen." has me a little concerned.

Of course none of these are my insurance which is BCBS Express Scripts through my employer. I see my hepatologist on Monday guess I will go from there.

Good luck to all,
Lynn

I have looked and can't find BCBS Express Scripts guidelines for retreatment. They must be purposely hiding it from the public.
Bucky

[lporterrn]

Bucky - I don't know if each state is specific - here is CA:
http://www.anthem.com/provider/noapplication/f0/s0/t0/pw_e225443.pdf?na

Harvoni (sofosbuvir/ledipasvir) may not be approved for the following:
II. Individual is using in combination with another nucleotide NS5B polymerase inhibitor[such as Sovaldi (sofosbuvir)];

[Bucky]

Bucky - I don't know if each state is specific - here is CA:
http://www.anthem.com/provider/noapplication/f0/s0/t0/pw_e225443.pdf?na

Harvoni (sofosbuvir/ledipasvir) may not be approved for the following:
II. Individual is using in combination with another nucleotide NS5B polymerase inhibitor[such as Sovaldi (sofosbuvir)];

Lucinda,
Thank you for the info!  They seem to be the only ones that have the tables for staging liver damage. I don't know what to make of that.
Bucky

[Lynn K]

Hi Lucinda

The one that worries me from the link you provided is

Harvoni (sofosbuvir/ledipasvir) may not be approved for the following:

IV. Individual is requesting the regimen for re-treatment and either failed to achieve a SVR or relapsed after achieving a SVR during a prior successfully completed treatment regimen consisting of sofosbuvir.

And as Bucky noted Accredo Express Scripts is playing it pretty close to the vest.

Happy Halloween to all
Lynn

[Islandgirl]

Does anyone have experience with, or knowledge about, Humana Choice Regional PPO (Medicare health plan with prescription drug coverage)?  I live in FL and had applied for Sovaldi but was required to get another viral load and have heard nothing back.  Now that Harvoni is approved I want to change to that since I'm genotype 1b and treatment naive.  Thanks!

[Bucky]

Does anyone have experience with, or knowledge about, Humana Choice Regional PPO (Medicare health plan with prescription drug coverage)?  I live in FL and had applied for Sovaldi but was required to get another viral load and have heard nothing back.  Now that Harvoni is approved I want to change to that since I'm genotype 1b and treatment naive.  Thanks!

Hello Island girl,
Sorry, I don't know about Humana at all.
But I wanted you to look at this: http://www.hepmag.com/articles/express_scripts_abbvie_switch_2831_26351.shtml

The Abbvie 3d had nearly 100% for geno 1B. I went with Sovaldi & Olysio because 5 months ago it was one of the best. Now it has been knocked down because of Harvoni and soon to be approved meds. Express Scripts is my carrier so I would say that is I relapse then I will use the 3d combo since I would have to use Harvoni for 24 weeks because it contains Solvaldi.
Isn't it exciting that we have so many treatment options!
Bucky

[Islandgirl]

Hi Bucky,

Yes, I agree that it's exciting - thanks for the link - and for writing me:)  I evidently wound up with Hep C from a blood transfusion many years ago.  I learned about it after I tried to donate blood at the bloodmobile and received a letter from them explaining that I could not be a donor.  I went to my doctor and then on to a gastroenterologist to learn about all this since I'd never even heard of Hep C.  Then, being a "research it first" kind of gal, I refused treatment since I could find nothing to make me feel that available treatment would gain anything but misery.  My current doc would not put me through the treatment until now since it would have been worse than my HCV with little hope for cure (thank God for this realistic woman).  Now we are in agreement the HCV progression and the new treatments that will work for my genotype are worth giving it our best shot!

Bucky, I hope and pray you'll soon be getting those great results on your tests - I'll keep you in positive thought and look forward to seeing your post! 
Islandgirl 

[dragonslayer]

More info on plans. United Healthcare is now NOT covering Harvoni unless at stage 3 or 4
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Pharmacy%20Resources/Harvoni_Medical_Necessity.PDF

Kaiser is also holding off.

Aetna looks fabulous:
http://www.aetna.com/products/rxnonmedicare/data/2014/GI/hepatitis_c.htm[/b]l

lporterrn,

Please advise if you get any updates on this Aetna certification criteria.  It certainly appears to be one of very few not requiring advanced liver disease for treatment.. But we saw the same thing with United Healthcare, and then they radically changed their criteria in short order.

Im waiting to hear from my carrier on the Harvoni prescription my  Dr. ordered by way of the specialty pharmacy he uses, and with a medicare open enrollment deadline rapidly approaching, I may have to switch carriers.. Id hate to do it based on certification information that may be incomplete or dated.  Im stage/grade 0-1 with a viral load of 2.4mil and genotype 1a, and am reviewing my alternatives in the eventuality I get declined.  Seems my options are 4:  Switching medicare advantage providers, applying to MySupportPath, waiting to get sick enough to pass the certification criteria (what a weird criteria for those who profess to be interested in our health) or private pay.   The Dec 7 deadline for open enrollment adds some urgency to the equation.

Thanks,
Dragonslayer

[Lynn K]

After a struggle with express scripts I received Harvoni from FedEx this morning starting treatment next Thursday 11/20 for 24 weeks. I was diagnosed with cirrhosis F4 in Jan 2008 but had problems because I relapsed on Sovaldi/Olysio. But finally got it sorted out after a long and somewhat annoyed, cranky, dissatisfied with their "service" e mail

Good luck all
Lynn

[Bucky]

After a struggle with express scripts I received Harvoni from FedEx this morning starting treatment next Thursday 11/20 for 24 weeks. I was diagnosed with cirrhosis F4 in Jan 2008 but had problems because I relapsed on Sovaldi/Olysio. But finally got it sorted out after a long and somewhat annoyed, cranky, dissatisfied with their "service" e mail

Good luck all
Lynn

Lynn,
Yea!!!!!!!!!!!!!!!!!!!  I am so happy for you and it gives me hope should I need Harvoni. 

Bucky

[badbradley]

Lynn   GOOD FOR YOU ! ! !  It makes my day when someone wins this stinkin' battle.
         And I thought I was "BAD" 
                                                     Lynn is "BAD ASS" !!
                                     Bad Brad
                                                                                   

[Lynn K]

Thanks Bucky and Bad Ass Brad lol

Well she's bad, bad, bad ass Lynn. I like it 

[mike4777]

Can anyone recommend an insurance plan that might cover Harvoni.  I have HepC Type 1B between btw stage 1-2.  I 've been turned down by Health Republic and am looking to switch  Jan 2015.   THX Mikeny

[BattleTheBeast]

Mike,

It's a crap shoot, depends on many factors and no way to tell who will cover and who won't honestly.

Hope it all works out and you get treatment soon,

~mel~

[Mike]

Hi Mike,

This article does a good addressing the issue with approving coverage/payment for the new Hep-C.

Interestingly, the American Association for the Study of Liver Disease (AASLD) has played a significant role in the approval/denial role....

"In the past year, new hepatitis C drugs that promise higher cure rates and fewer side effects have given hope to millions who are living with the disease. But many patients whose livers aren’t yet significantly damaged by the viral infection face a vexing reality: They’re not sick enough to qualify for the drugs that could prevent them from getting sicker.

An estimated 3 million people have hepatitis C. Faced with a cost per patient of roughly $95,000 or more for a 12-week course of treatment, many public and private insurers are restricting access to those who already have serious liver damage. Other strategies that limit access include restricting who can prescribe the drugs or requiring early proof the drug is working before continuing with treatment. In addition, many state Medicaid programs require that patients be drug and alcohol free for a period of months before they can get the hepatitis C drugs.

“Everybody is trying to figure out how best to deliver needed treatments without blowing out resources because of the cost,” says Brendan Buck, a spokesman for America’s Health Insurance Plans, a trade group. AHIP has been an outspoken critic of high prices for specialty drugs.

Insurers base their coverage decisions in part on practice guidelines issued by clinical groups such as the American Association for the Study of Liver Disease (AASLD). That organization recommends giving patients with advanced liver disease priority in treatment. “Limitations of workforce and societal resources may limit the feasibility of treating all patients within a short period of time,” the organization said in a press release announcing the recommendations.


Paul Walker is one of the healthy ones. For the first time in many years, the self-employed computer systems consultant has health insurance, a silver-level HMO from Blue Cross Blue Shield of Texas for which he pays $211 a month to cover himself and his wife. (Walker had earlier investigated getting insurance through Texas’ high-risk pool but balked at the $1,200 monthly premium for two people.)

Diagnosed with hepatitis C in 1998, the 53-year-old Tyler, Texas, resident was thrilled to learn that his liver is still basically healthy. A biopsy showed only slight evidence of the fibrous scar tissue that can cripple the liver, eventually resulting in cirrhosis or liver cancer.

Many baby boomers who have hepatitis C contracted it years ago from blood transfusions at a time when blood was not screened for the virus.
Walker’s doctor prescribed Sovaldi, a pill approved by the Food and Drug Administration in December that can cure the chronic infection in 12 weeks, significantly faster than the nearly year-long course of treatment often required under older drug regimens. Sovaldi must be taken with another hepatitis C drug such as interferon, which can cause flu-like symptoms, nausea and depression and which adds to the cost. Instead of interferon, Walker’s physician prescribed Olysio, another recently approved hepatitis C drug that is popular among physicians. But its use in combination with Sovaldi for cases like Walker’s hasn’t been approved by the Food and Drug Administration.

Walker’s insurer denied his physician’s request for the drug. Walker appealed the denial and was turned down again. The insurer cited the off-label use of Olysio in its denial, but Walker says he doesn’t think an approved combination of drugs would have changed the decision. The insurer generally doesn’t approve Sovaldi for patients like Walker, whose liver fibrosis is stage “F1” on scale of F0 to F4, he said. Only patients with more severe liver damage, stage F3 or F4, are typically approved for Sovaldi.

“We are committed to providing our members access to quality, cost-effective medications,” Dan McCoy, chief medical officer for Blue Cross Blue Shield of Texas, said in a statement. “Our coverage criteria is based on clinical trial data, published literature and recommendations from a wide variety of medical specialty societies. We constantly review and update our coverage criteria as new information becomes available or new specialty drugs or treatments come to market.” The insurer didn’t respond to a request for specific coverage criteria.

In October, the FDA approved another hepatitis C drug, Harvoni, a daily pill that doesn’t have to be taken with another drug. A typical 12-week course of treatment will generally cost about the same as for Sovaldi used with another drug (unless it’s Olysio, which can push the total treatment cost to $150,000 or more). Patients like Walker might be cured in as little as eight weeks using Harvoni, however, slashing the cost by a third.

Walker says he hopes he’ll be approved for Harvoni.

“The fact that I’m only F1, that’s good,” says Walker. “But until I actually get the medication and am cured there’s going to be a lot of anxiety.”

Many baby boomers who have hepatitis C contracted it years ago from blood transfusions at a time when blood was not screened for the virus. Walker believes he got it following a childhood accident that sent him to the hospital. Others got it from contaminated needles while experimenting with injection drugs. Now, hepatitis C infections are on the rise again as a new generation of prescription opioid abusers moves from pills to injection drugs.

According to the Centers for Disease Control and Prevention, up to 70 percent of people infected with the hepatitis C virus will develop chronic liver disease and up to 20 percent will eventually develop cirrhosis, a severe scarring of the liver. Up to 5 percent will develop liver cancer.

Patient advocates say that in addition to helping individual patients avoid health problems down the road or infecting others, the new drugs present an enormous public health opportunity.

“We can address hepatitis C and eradicate it,” says Ryan Clary, executive director of the National Viral Hepatitis Roundtable, an advocacy group."


Best wishes, Mike

[dragonslayer]

Hi Mike,

Thanks for the informative post. Not sure I understand the approach and recommendation of AASLD, nor the tact the insurance companies are taking though.

I understand that Harvoni is prohibitively expensive...And I understand that the prospect of covering 3 million patients, and potentially many more, is daunting to the insurance companies.  But what I dont understand is why the short sighted approach.   Surely they must be aware that HCV is a progressive illness, and that the rate of progression, particularly among boomer aged patients, is not linear... So its a choice they have to make of either  covering folks like me who have only minor liver damage now, or covering us later when we're sicker and at risk of incurring far greater costs.   Either way, the insurance companies arent going to escape paying, so why dont they choose the more economically feasible alternative?

This is like running into the pre-existing condition insurance denials all over again.. Only this time, we're not too sick to cover; we're not sick enough!!!    Are we supposed to start imbibing alcohol in large enough quantities to push our livers to the breaking point so that we can be cured?   Who ever thought that finally, the cure we've all been waiting for is here, and FDA approved, just waiting to be prescribed, and irony of ironies, the insurance companies say, 'only if youre sick enough'....?!

[Mike]

Another issue with insurance approval is that 80% of those infected with Hep-C don't show signs of the infection, don't have symptoms from the infection and never develop liver disease/damage. This means 8 out of 10 people with a chronic Hep-C infection wont develop any clinical symptoms other than a positive test for the Hep-C antibody and a detectable serum viral load.

Because of this factor, the insurer (on a case-by-case basis) can argue that the disease hasn't shown progression to a level that warrants the cost of treatment, may never progress beyond a chronic infection and can be managed by simply monitoring it over time.

As the cost of treatment decreases, this may change.

However, as the AASLD notes "societal resources may limit the feasibility of treating all patients."

My hope is that everyone can be treated and that this disease will be eradicated.

Realistically, however, this maybe cost prohibited given the scarce medical dollars currently available.

Best wishes, Mike

[huxley]

My gastroenterologist put in for 24 weeks of Harvoni. I am 1a, what she said was a high viral load, massive splenomegaly and other issues(cryoglobulinemia, vasculitis, and bone marrow failure). I have progressed into cirrhosis apparently but I've been infected over 40 years--first with B (now chronic) and C.


My question is: All of the other treatments did not work, can't take ribavarin due to multiple blood transfusions and I certainly can't afford a co-pay although my insurance is BCBS/Carefirst.


Anyone else have luck with Carefirst BCBS approval? Thanks in advance.

[Lynn K]

Hi Huxley
You should have no trouble getting coverage since you have cirrhosis. For copay assistance contact My Support Path from Gilead Pharmacuticles the makers of Harvoni.

1-855-769-7284
http://www.mysupportpath.com

They have been great providing assistance to patients

Best of luck
Happy Thanksgiving
Lynn

[huxley]

Thanks so much. For some reason--possibly since I have not seen a gastroenterologist since 2007, the insurance company is only offering 8 weeks with ribavarin. There is a lot to go through from the nurse who told me. They came back with 8 weeks and ribavarin. Unrealistic with my labs and stage F4. It appears my state or some kind of situation is making them very cautious. If approved I will certainly try the payment method from the drug company.


Thanks for the quick reply.