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Author Topic: Harvoni and Viekira PAK denied as Plan Exclusion is that appealable or finate?  (Read 20892 times)

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Offline Kel

  • Member
  • Posts: 18
  • Kelly
My insurance, UHC Choice, denied Harvoni and the appeal as they state it's a plan exclusion. Now my doctor wants to try new med just released Viekira PAK but I see that it is also a plan exclusion. Are plan exclusions appealable through the employer or insurance? What other options do I have to get these treatments as I can't take ribavirin or interferon as I have retinitis pigmentosis and those meds are known to cause blindness in certain patients. I was so hopeful and now I am a puddle.

Offline Kel

  • Member
  • Posts: 18
  • Kelly
Update I didn't want to create a new post and didn't know how to indicate that this was an update. When I last posted UHC Choice had denied Harvoni and Viekira PAK as plan exclusions' and I was feeling pretty down about that. I am HCV g1a and treatment naïve, my VL is over 800 and I am F2 by FibroScan (I think that was the blood test). I am symptomatic and have been for years, symptoms the last 2 weeks have become life changing for me. I called Gilead Sciences just before Christmas to see if there was anything to be done. They looked me up and filled in the missing information and said they'd be in touch. This past Friday they called my doctor and I have been pre-approved for Harvoni all they need is my doctors signature. Since I have fatigue, nausea, and headaches daily I am not concerned [overly] about these side effects. I am grateful for this forum, thank you.

To anyone who might need it:

To learn more about Support Path for Sovaldi® and Harvoni®, please call 1-855-769-7284, Monday through Friday between 9:00 a.m. and 8:00 p.m. (Eastern Time). - See more at: http://www.gilead.com/responsibility/us-patient-access/support%20path%20for%20sovaldi%20and%20harvoni#sthash.SCfUZAFL.dpuf

Offline BattleTheBeast

  • Member
  • Posts: 817
  • Female, 57 - SVR12 as of 7/23/15!!
Kel,

That's the best news ever! Happy New Year to you. good job following up and advocating for yourself!

Honestly hope you get your medication quickly and get on the road to SVR.

Feel better and congrats again!!

Mel
~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 Kel

  • Member
  • Posts: 18
  • Kelly
Mel,

Thank you for your help. I am excited and scared, mainly excited. I called it viral load and it's SVR d'oh  :-[

Sincerely,

Kel

Offline Sam1224

  • Member
  • Posts: 62
Congrats. I took my 2nd Harvoni tablet today. Hopefully you get yours in hand soon so you can start. I had a mild headache last night and none so far today. I seem to have extra energy. It may just that I'm so excited to finally be in therapy with Harvoni.

Offline mvnwy

  • Member
  • Posts: 8
Hi Sam, I saw that you have started Harvoni treatment.  Would you mind me asking what insurance company and what level of plan (silver, etc) allowed that?  I am planning to sign up for new insurance tomorrow and had heard some companies were no longer paying for Harvoni unless there was stage 2 or 3 cirrhosis.  Mine is stage 1 so I may have to use the support path instead.

Also, how is the treatment going? 

Thank you so much for your reply.

Offline BattleTheBeast

  • Member
  • Posts: 817
  • Female, 57 - SVR12 as of 7/23/15!!
Hi Sam,

Welcome to the Harvoni crew! I find that drinking lots of water really helps with headaches.

Pretty exciting and scary to take that first pill and then it's a snap!

Mel
~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 Sam1224

  • Member
  • Posts: 62
mvnwy

I am with Anthem Blue Cross but I slipped in just in the nick of time. At the time they were using Express scripts. I would call them or check their formulary to see if they are still doing business with Gilead.
The Harvoni regimen is convenient and tolerable but I personally would start with any of the new drugs if your Dr seems to think it's appropriate.
FYI there are any number of people here that are WAY better informed about this than I am. Start a new topic with your question and I'm sure you will get your questions answered.

Offline Red Hen

  • Member
  • Posts: 187
Hi. I am not an expert on this but from what I've read here in the forums, any decision by an insurance provider can be appealed. It seems like the doctors are the ones who get best results. Best of luck to us all!
genotype 1a
completed 12 weeks Viekira pak and ribavirin
final results due around the end of April
Undetected 12 weeks post treatment!

Offline SickTired1

  • Member
  • Posts: 23
I actually know the answers to Kel's questions re appeals to plan exclusions and self-insured employers,  so I'm going to answer them in case someone else is in same situation and visits forum.   

The chances of successfully appealing plan exclusions in this situation are basically nil, but you still need to take the steps in order to support your application for patient assistance from Gilead.

I too was told the drugs were a plan exclusion.  First thing to do is follow the instructions of the denial form letter and request a copy of the file that was used to generate the denial(s). Also, immediately request your provider to appeal, until you've exhausted the process, usually the initial request is followed by two appeals.  You will need to prove to Gilead that you have been denied a couple times before you are past first hurdle of eligibility for assistance from them. You will need the above-mentioned file to send to Gilead with your application for assistance.  Do not be daunted by the income level requirement.  Apply anyway.

Meanwhile, back at Rancho Insurance Company, calling the customer service number on your insurance card will yield nothing but some poor schmuck who is just trying to do his or her job, quoting scripted answers that say nothing. It will be the appeal denial letters that will inform you that UHC is merely the administrator and not the actual insurer because the employer is self-insured.  This means they operate under a whole different set of rules, ERISA, and are not subject to state law, so you can't complain to your State Commissioner.  Well, you can, of course, but they have no jurisdiction.

So the second thing you need to do is request a Plan Summary Document direct from your employer and read it to find out how they put drugs into the formulary and whether or not you can request an external review by an outside specialist following the final denial from the plan administrator (in this case, UHC).

I requested, and received, an external review, which was a joke... the doctor cited stats that didn't fit my profile and did not use the studies I had pointed out. Actually said to take Sovaldi with Interferon and Ribavirin.  Soooo last week.   Then the insurance company sent me a letter saying I wasn't eligible for external review, after it was completed.  Ha ha! 

It helps if someone in the Human Resources Dept of the employer will talk to you, even if they don't tell you what you want to hear, they can say things more humanely than the form letters.  Also, don't discount the fact that your boss CAN wave a magic wand and get you covered.  It is their plan. They own it and can do whatever they want, including help you out in this way if they are high enough up the corporate ladder.  If you are worried about bankrupting them, know that self-insurers usually carry re-insurance or participate in some type of pool that picks up the tab after a certain limit is met.

You kind of need to balance the appeals process and the assistance program pathways in tandem and hope one of them pans out. Sometimes the only recourse is to get an attorney. Or just be patient and wait for the tx to make its way into the formulary.   I found this last recommendation to be completely impossible, though.  For me, Gilead stepped up to the plate and granted me assistance even though our income level was over the limit.  I do not know why, but I start treatment tomorrow and am not going to question their reasons.  Harvoni and Viekirk remain excluded from the plan for the time being.

Now you know everything I know about insurance formularies and plan exclusions as related to self-insured employers, as seen through the glass of my own experience.
Geno 1A, Il28bTT
Female, age 64
Inf late 60's/early 70's
Dx October 2012
F4, Childs Pugh A
Triple therapy June 2013-May2014 (pegint/riba/telaprevir) Relapsed June 2014
Harvoni/Riba 1200 mg day started Jan 2015

Offline BattleTheBeast

  • Member
  • Posts: 817
  • Female, 57 - SVR12 as of 7/23/15!!
SickTired,

Great informative post, thank you so much! That's really going to help a lot of people with the crazy process dealing with a Self Insured Company. It's a whole other world exactly as you explained.

I am so happy you were able to get Gilead to approve you and will start the TX tomorrow. That's so amazing and as much as people have complained about the pricing Gilead has really stepped up to help people over and over again. I haven't heard they did not help from anyone yet if you followed the process they need. Maybe the method behind the madness is that Gilead is using some of the profits from those that are approved to provide the medication to those that aren't. Who knows? I am just happy to hear you are approved and on your way to SVR!

Mel
~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 SickTired1

  • Member
  • Posts: 23
Thanks, Mel. 

I also need to do a shout out to the University of California at SF pharmacy techs who helped a lot with encouragement and also having another "way in" with Gilead; they definitely worked on things from their end, too. 

I didn't put that in the post because from what I'm reading a lot of us don't have liver clinics but regular docs not that used to, or equipped to handle, the detailed logistics between drug manufacturers, specialty pharmacies and insurance companies. It will be all the patient can do just to have the doctor sign the Gilead application form.  These patients are kind of left on their own.  UCSF provides pretty good advocacy. Thank you, UCSF!

Good to hear from you!  The first Harvoni Eagle has just landed in my tummy!  Yay!  Off to work...



Geno 1A, Il28bTT
Female, age 64
Inf late 60's/early 70's
Dx October 2012
F4, Childs Pugh A
Triple therapy June 2013-May2014 (pegint/riba/telaprevir) Relapsed June 2014
Harvoni/Riba 1200 mg day started Jan 2015

Offline Red Hen

  • Member
  • Posts: 187
Excellent post, SickTired!
genotype 1a
completed 12 weeks Viekira pak and ribavirin
final results due around the end of April
Undetected 12 weeks post treatment!

Offline SickTired1

  • Member
  • Posts: 23
Thank you, Red Hen!
Geno 1A, Il28bTT
Female, age 64
Inf late 60's/early 70's
Dx October 2012
F4, Childs Pugh A
Triple therapy June 2013-May2014 (pegint/riba/telaprevir) Relapsed June 2014
Harvoni/Riba 1200 mg day started Jan 2015

Offline denied

  • Newbie
  • Posts: 2
Hi all.  Feeling really frustrated with Insurance now.  Denied twice by Express Scripts, now on appeal.  They want me to take V Pak but my doc says not appropriate for me.  I've got the gilead Support Path started, and as 2 last resorts, I can appeal directly to my Insurance Co. or get a lawyer (my best friend) involved.  He actually looked over paperwork and said it is not legal for Express Scripts to deny coverage because they do cover in specialty pharmacy, which they own.  I've gotten run around for 7 weeks now, as the virus rages on.  Express Scripts only worth about 30 billion!!!
Lawsuit could take years though, so I keep dealing with denials.  Attorney General says call board of pharmacy who says not their problem.  My ins. co. says call express scripts, express scripts says call ins. co. Runaround runaround.  I'm sorry, so frustrated.  Support path could take 6 weeks.  Ugh!  Any advice?  xo all

Offline morning_glory

  • Member
  • Posts: 104
  • This is the first day, of the rest of your life...
denied - "Ugh! Any advice?" 
Yes, be patient and keep fighting/advocating! Your health is worth it!
Just don't get too dizzy from the "runaround runaround"  ;)
 
My doc prescribed Harvoni 11/19/14... I'm still waiting and playing the game. Several times, I have wanted to say the "heck w/ all this"! Then I get back in the game of advocating for myself. (I now have a Case # w/ Support Path)

SickTired1 - Great post!!!  :)

MG
Likely infected - mid 70's / Diagnosed - mid 90's
Geno type - 1a
AST - 45
ALT - 51
Viral Load - 435,120
Liver Biopsy 6/2004 - F1-2
Fibrosure 5/2011 - F1-2
Fibrosure 2/2014 - F-0
Treatment Naive, prior to Harvoni
Harvoni started on 5/16/15
8-week Treatment Completed (7/10/15)
4-week bloodwork (6/11/15) Undetected, AST 15, ALT 17
8-week bloodwork (7/13/15) Undetected, AST 14, ALT 16

Offline denied

  • Newbie
  • Posts: 2
Are you doing the Gilead support path?  They told me as long as you make under $100,000.you could get for free.  Hope so! 

Offline Lynn K

  • Global Moderator
  • Member
  • Posts: 4,543
  • Get tested, get treated, get cured, fight Hep c!
Try writing to this email address and explain why you need Harvoni and cannot take Viekira Pack.

expressrxhelp@express-scripts.com

I was denied Harvoni initially because I relapsed on Sovaldi Olysio last year. Turned out they had me listed as non responder or partial responder to tx when in fact I was undetectable on treatment. So I wrote a impassioned email describing my health situation and I wrapped it with "I am frustrated to the point of considering contacting my local media to bring to light the cavalier and indifferent way express scripts treats their patients and their health problems."

They called me the next day and I had the meds in hand the next day after that.

At least 5 other people have contacted this address an were able to get Harvoni, it hasn't been 100 percent but doesn't hurt to give it a try.

Good luck
« Last Edit: February 22, 2015, 03:39:41 am by Lynn K »
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 morning_glory

  • Member
  • Posts: 104
  • This is the first day, of the rest of your life...
Are you doing the Gilead support path?  They told me as long as you make under $100,000.you could get for free.  Hope so!

I just started the process with the Gilead Support Path.

Go to the link below:
Support Path  -  http://www.mysupportpath.com/getting-started

Providers and patients can call 855-769-7284 for assistance.

Hope this helps.

Blessings
MG
Likely infected - mid 70's / Diagnosed - mid 90's
Geno type - 1a
AST - 45
ALT - 51
Viral Load - 435,120
Liver Biopsy 6/2004 - F1-2
Fibrosure 5/2011 - F1-2
Fibrosure 2/2014 - F-0
Treatment Naive, prior to Harvoni
Harvoni started on 5/16/15
8-week Treatment Completed (7/10/15)
4-week bloodwork (6/11/15) Undetected, AST 15, ALT 17
8-week bloodwork (7/13/15) Undetected, AST 14, ALT 16

Offline Lynn K

  • Global Moderator
  • Member
  • Posts: 4,543
  • Get tested, get treated, get cured, fight Hep c!
For me it was good that I was able to get prescriptions through Express Scripts because I did not qualify for Gilead support path
« Last Edit: February 22, 2015, 02:07:46 pm by Lynn K »
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 sawsome

  • Member
  • Posts: 13
John | March 9, 2015 11:58 PM
I am an American living in Brisbane Australia. Harvoni has NOT been approved here. I am in stage 4 cirrhosis with chronic Hep C 1a. My platlette count is below 30 and I can not receive any other treatment (interferon).
My Australian free health care doctor says my best bet for survival is to return to the USA. I read the supportpath web portal and max offered is 16k in discounts. Im on disability now and things are getting worse. In the process of selling what little I have as far as assets go (less than 15K in total) minus 2k in flights and with exchange rates I will have roughly 6 or 7 K once I land in Columbus Ohio which is where Im from. I have 3 children and 3 grand children I would like to spend what life I have left with. Im 60 yrs old and just lost in a cloud over this. Im a carpenter so after childrens educations were paid for Im broke. I dont understand why they could save my life in 48 weeks and it seems impossible for me to get help. ALL advice is welcome and Thank you in advance. John Vance

Offline sawsome

  • Member
  • Posts: 13
John | March 9, 2015 11:58 PM
I am an American living in Brisbane Australia. Harvoni has NOT been approved here. I am in stage 4 cirrhosis with chronic Hep C 1a. My platlette count is below 30 and I can not receive any other treatment (interferon).
My Australian free health care doctor says my best bet for survival is to return to the USA. I read the supportpath web portal and max offered is 16k in discounts. Im on disability now and things are getting worse. In the process of selling what little I have as far as assets go (less than 15K in total) minus 2k in flights and with exchange rates I will have roughly 6 or 7 K once I land in Columbus Ohio which is where Im from. I have 3 children and 3 grand children I would like to spend what life I have left with. Im 60 yrs old and just lost in a cloud over this. Im a carpenter so after childrens educations were paid for Im broke. I dont understand why they could save my life in 48 weeks and it seems impossible for me to get help. ALL advice is welcome and Thank you in advance. John Vance

Offline Red Hen

  • Member
  • Posts: 187
I hope you will be able to get a better discount for Harvoni on appeal! In the mean time take care of yourself. There are new drugs coming out almost every day. Lots of good information in this forum.
genotype 1a
completed 12 weeks Viekira pak and ribavirin
final results due around the end of April
Undetected 12 weeks post treatment!

Offline sawsome

  • Member
  • Posts: 13
Thank you Red Hen and others for this information. John

 


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