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Author Topic: What if Harvoni is NOT on your "NEW" Insurance Formulary?  (Read 7052 times)

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Offline Roger

  • Member
  • Posts: 171
What if Harvoni is NOT on your "NEW" Insurance Formulary?
« on: November 21, 2014, 01:00:40 am »
(I hope this is the correct section to post this note. I wish there was a section for insurance related comments)

A Medicare Part D question.... 

I have to go on Medicare January 1.
My present commercial insurance is covering my first 2 months of Harvoni.  (I get my first bottle tomorrow!)  They will not cover the third bottle because I will not be on their coverage during the time the 3rd bottle is needed (after January 1).

I have been researching various Part D plans for my area.  So far NONE of them have Harvoni on their formulary.  I have found Sovaldi on a few of them.

Does anybody have experience with this?

If I buy a "Part D" plan (knowingly) that does not have Harvoni on their formulary, will my doc be able to make a case for them to ok the prescription for my last needed bottle?

How does this work?

These bloody drug plans are priced "all over the board".  I'm a pretty smart guy, and know how to dig and analyze and it's difficult!  Those poor folks who don't use computers or only listen to an insurance agent are doomed in this Medicare game!

What to do?...


Genotype 1a
2006 - Dx
2009 Biopsy      - Stage 2
2013 FibroScan - Stage 2
2014 FibroSure - Stage 3

Started Harvoni 11.21.2014 Viral Load - 313,593
12.26.2014 - UND (at 5 weeks)
At 8 Weeks - UND
EOT 02/12/15 - UND
12 Week EOT Blood Work - UND

Offline Rubye

  • Member
  • Posts: 130
Re: What if Harvoni is NOT on your "NEW" Insurance Formulary?
« Reply #1 on: November 21, 2014, 05:15:59 pm »
I'm surprised your present insurance is refusing to pay for the last 4 weeks. It seems if they commit to your treatment they would be legally required to supply you with enough of the drug to allow you to complete it.

I have Express Scripts as my Part D and I have read that they are presently paying for it but may stop allowing Harvoni when the new Abbvie meds are released in January. Obviously, you would have a good claim of medical necessity but the new insurance is obligated to help you I don't think. I could be mistaken.

Why don't you wait until you have the new insurance? I also think Gilead will pay if you get stuck without.

Offline Roger

  • Member
  • Posts: 171
Re: What if Harvoni is NOT on your "NEW" Insurance Formulary?
« Reply #2 on: November 21, 2014, 05:31:11 pm »
Rubye,
I'm not sure Gilead will step in for Medicare on their free plan.
I know their coupon will not work with Medicare. I'll ask them about
their free assistance. Who knows. Good idea.
Genotype 1a
2006 - Dx
2009 Biopsy      - Stage 2
2013 FibroScan - Stage 2
2014 FibroSure - Stage 3

Started Harvoni 11.21.2014 Viral Load - 313,593
12.26.2014 - UND (at 5 weeks)
At 8 Weeks - UND
EOT 02/12/15 - UND
12 Week EOT Blood Work - UND

 


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