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Author Topic: Received Express Scripts denial letter for Harvoni  (Read 14410 times)

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Offline Lynn K

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  • Posts: 4,546
  • Get tested, get treated, get cured, fight Hep c!
Received Express Scripts denial letter for Harvoni
« on: November 11, 2014, 05:16:35 am »
The letter says:

We reviewed your request to obtain Harvoni tablet under your plan. We are unable to approve this request for the following reason.

The request is for retreatment of no or partial responders to Sovaldi / ribavirin with or without peg-interferon OR Sovaldi/Olysio with or without ribavirin...

In accordance with your plan provisions for drug coverage, A review has been performed. The review uses the plans rules and is based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective. Details of drug coverage are contained in your plan documents, and the review guidelines are available upon written request.

You or your representative may appeal this decision within 180 days of the receipt of this notice.

The appeal will be reviewed according to your plan provisions. A decision will be provided to you and your doctor within 15 days of receipt of your written request.

So basically 3 weeks after the doctor sends in the appeal so mid-December at best.

Lynn
« Last Edit: November 11, 2014, 05:18:22 am by Lynn K »
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 BattleTheBeast

  • Member
  • Posts: 817
  • Female, 57 - SVR12 as of 7/23/15!!
Re: Received Express Scripts denial letter for Harvoni
« Reply #1 on: November 11, 2014, 09:11:27 am »
Hey Lynn,

So they tell you why they deny you but don't tell you what exactly you need to do to get approved. Or if they did in that mumbo jumbo I didn't catch it.

"In accordance with your plan provisions for drug coverage, A review has been performed. The review uses the plans rules and is based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective. Details of drug coverage are contained in your plan documents, and the review guidelines are available upon written request."

I would write to them and make them send a copy of the drug coverage and the review guidelines along with what FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective.

At least someone can stand at the copy machine for a while....

~Mel~
Logged
~Mel~
Hep C, Type 1, 10/11  viral load 8,238,340, AST-60, ALT-57 Bili .6  Stage 4 cirrhosis,
Week 4 VL <15 AST 20 - ALT 27 Bili .9
Week 9 - switched to Harvoni VL UD!! AST 20 ALT 19
EOT date is 4/30/2015,
SVR 12 is 7/23/15 ACHIEVED!!! 
and SVR 24 ACHIEVED!!

Offline Lynn K

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Re: Received Express Scripts denial letter for Harvoni
« Reply #2 on: November 13, 2014, 02:38:35 am »
I finally found a back door into Express Scripts and got through to them!

I made a comment to an article on the express scripts site.

http://lab.express-scripts.com/insights/specialty-medications/reducing-failed-hepatitis-c-therapies-by-half

They responded and asked me to e mail them with my contact information to

ExpressRxHelp@express-scripts.com

So I did and sent them a summary of my medical history some comments about Sovaldi relapse vs what they had me labeled as a null or partial responder to Sovaldi along with supporting links for a clinical trial I found about Harvoni for Sovaldi relapse patients and other pertinent links.

My closing comments:

My personal feeling that Express Scripts cares more about their bottom line that the health of its subscribers. That your company is gambling with my life in the hope that later treatments like the AbbVie 3D combo will come in at a lower price point.

I am frustrated to the point of considering contacting my local media to bring to light my distress with my Express Scripts experience and their cavalier, indifferent attitude toward its customers and their health.

I said they could reach me after 10 am PST.... they called at 10:01 a manager at Accredo Express Scripts

I am approved for 24 weeks of Harvoni my first bottle is being sent Fed Ex over night I should have it before 10 AM tomorrow!

Gosh I hope this works, I sure don't want to have to come back asking for AbbVie.

Good Luck everyone
Lynn
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 BattleTheBeast

  • Member
  • Posts: 817
  • Female, 57 - SVR12 as of 7/23/15!!
Re: Received Express Scripts denial letter for Harvoni
« Reply #3 on: November 13, 2014, 07:38:04 am »
YOU DID IT LYNN!! HOORAY!!


BTW, Lynn mentioned something really important, Express Scripts will not handle these medications, they are all sent to Accredo which is the company they have for these types of illnesses and medications. If anyone is fighting with Express Scripts please try going to Accredo and ask to talk to a supervisor. The number is 1-877-ACCREDO (222-7336) and the website is www.accredo.com

Express Scripts is not handling these medications and you can be lost in a maze dealing with them.
« Last Edit: November 13, 2014, 07:41:27 am by BattleTheBeast »
Logged
~Mel~
Hep C, Type 1, 10/11  viral load 8,238,340, AST-60, ALT-57 Bili .6  Stage 4 cirrhosis,
Week 4 VL <15 AST 20 - ALT 27 Bili .9
Week 9 - switched to Harvoni VL UD!! AST 20 ALT 19
EOT date is 4/30/2015,
SVR 12 is 7/23/15 ACHIEVED!!! 
and SVR 24 ACHIEVED!!

Offline butterfly1

  • Member
  • Posts: 4
Re: Received Express Scripts denial letter for Harvoni
« Reply #4 on: January 22, 2015, 11:34:21 am »
Express Script just denied my coverage for Harvoni.  Can I sue them?  How dare they think it's ok to play the devil's advocate with my life.  If I go through Accredo what are my chances of getting approved?  I am Geno type 1 with no cirrhosis of the liver. 
« Last Edit: January 22, 2015, 11:51:41 am by butterfly1 »
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Offline Lynn K

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  • Get tested, get treated, get cured, fight Hep c!
Re: Received Express Scripts denial letter for Harvoni
« Reply #5 on: January 23, 2015, 01:57:05 am »
Accredo is Express Scripts they are the specialty pharmacy drug provider for them. The decision on if you qualify is from Express Scripts if they are your prescription drug provider.

Express Scripts/Accredo has a deal with Abbvie making them the preferred drug Viekira Pak for treatment of Hep C. They will provide Harvoni only if you do not qualify for Viekira Pak.

http://www.reuters.com/article/2014/12/22/express-scripts-abbvie-hepatitisc-idUSL1N0U50M120141222

"Express Scripts to cover AbbVie hepatitis C drug, drops Gilead treatment"

If you are Genotype 1a or 1b and do not have advanced cirrhosis my understanding is your only option is Viekira Pak.

If you get 2 letters of denial you could contact http://www.mysupportpath.com/
 Or call 1-855-7-MYPATH(1-855-769-7284) to register over the phone.

Is there a reason you cannot take Viekira Pak? You could try to appeal on that basis to the email address above in the thread: ExpressRxHelp@express-scripts.com   but based on your not having cirrhosis I unfortunately doubt you will have any success.

So sorry for your difficulties but the way I see it is either go with Viekira Pak, see if Gilead will help they will pay the entire cost for those who qualify, or get different insurance if you can.

Good luck
« Last Edit: January 23, 2015, 02:04:27 am by Lynn K »
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 Mott the Hoop

  • Member
  • Posts: 12
Re: Received Express Scripts denial letter for Harvoni
« Reply #6 on: February 13, 2015, 09:22:28 am »
Hi Lynn , found your post this morning & wanted to let you know my thoughts & prayers are with you . Just found out a few days ago my friend didn't respond after sovaldi & interferon last summer . He's hoping to get started on 24 weeks of Harvoni soon , I'll have to get him to this site & read your posts . He's a little bummed his last treatment didn't work . I hope you are well today & remembering to drink plenty o' water ! God bless , Mott the Hoop  8)
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Offline Lynn K

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  • Get tested, get treated, get cured, fight Hep c!
Re: Received Express Scripts denial letter for Harvoni
« Reply #7 on: February 14, 2015, 03:33:10 am »
Yeah I was bummed you could say when I relapsed in September after treating for 12 weeks with Sovaldi Olysio.

I started 11/18/14 with Harvoni and added Ribavirin on Jan 20. Going to have to dose reduce the ribs because my hemoglobin is down to 9.3

Good luck
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 kate0b1

  • Member
  • Posts: 293
Re: Received Express Scripts denial letter for Harvoni
« Reply #8 on: February 14, 2015, 05:39:30 am »
@lynnk, I'm sorry your h&h dropped again, how much are you on and what will they drop it to? Are you feeling well (except the low h&h)?

kate

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Offline Lynn K

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  • Posts: 4,546
  • Get tested, get treated, get cured, fight Hep c!
Re: Received Express Scripts denial letter for Harvoni
« Reply #9 on: February 14, 2015, 06:15:02 am »
I feel fine people said I look pale. Even did my annual upper endoscopy yesterday to check to make sure my esophageal varicies have not returned since I had them banded.

My pills are 600Mg so my doctor asked for a new script which I guess I will have next week. she is reducing me from 1200 to 1000. I have heard if I go below 8.5 they will discontinue the riba.

As I only have 600 mg  tablets on hand I have been told to just take 1 tablet a day until we can get the 400/600 ribapak
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 Islandgirl

  • Member
  • Posts: 295
  • Started Harvoni 12/3/14 - EOT 2/25/15
Re: Received Express Scripts denial letter for Harvoni
« Reply #10 on: February 14, 2015, 08:45:58 am »
God bless you Lynn.  You are such a warrior, an inspiration to us all.  I know you are in the thoughts and prayers of all of us - we're your Team.  Hugs, ...Islandgirl
Logged
1b, treatment naive, positive for Hep C since 1994; thought to be transmitted via blood transfusions in 1976
Started Harvoni 12/3/14, EOT 2/25/15
12/31/14 labs - Virus Undetected, ALT/18, AST/34
3/25/15 labs - 1 mo post 12 wk Harvoni TX Virus Undetected!!  :) ....Islandgirl

Offline kate0b1

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  • Posts: 293
Re: Received Express Scripts denial letter for Harvoni
« Reply #11 on: February 15, 2015, 07:16:54 am »
@lynnk, i hope the lowered dose works, fingers crossed. you have been on it before correct? what was the lowest it went then?

kate
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Offline Lynn K

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  • Posts: 4,546
  • Get tested, get treated, get cured, fight Hep c!
Re: Received Express Scripts denial letter for Harvoni
« Reply #12 on: February 15, 2015, 02:14:27 pm »
When I was taking interferon and riba I was down to 8 something when they added epotin to bring it back up.

I guess if 1000 is still too much we will reduce from there. Until I get the new script I am only taking 600 just one pill a day.

Thanks
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!
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