denied for Harvoni from insurance!

[Daddysgirl]

Now getting help through specialty Co. Anyone go down this road I'm 3 weeks into that part .of course anxious

[HHburme]

I was turned down initially. My Dr wrote an appeal and went through Walgreen's specialty pharmacy and then was approved. It took 3 weeks or so. Hang in there.
JB

[BattleTheBeast]

I think they deny almost everyone at first these days.

If you could share who you are working with maybe we can provide some additional feedback for you on the things that worked for us.

Mel

[Daddysgirl]

First turned down Twice from B.C.B.S. Then G.I. TurnrEd it over to specialty Pharm. it's been a month now . We should qualify by our income!  I'm grade 1 stage 1 ,I have talked to them twice . Seems like a year!  Know there people a lot sicker ! It's been 7 months since they told me its active,not sure if that the right term? I've know about a year and a1/2.

[HHburme]

Daddysgirl.....hoping and praying you will get your meds.

[Roger]

Frankly, I think that most doc's offices do not know how to write up a decent request for the insurance companies.  Ditto when it comes to writing up an appeal.

They leave out important medical history facts (about you), they take things for granted (like the insurance companies have ESP), they don't "elaborate" on your medical problems enough, and so on.  All too many doc's offices treat this like they are writing a regular prescription.  Getting a $94,500 12 week prescription ok'd is A LOT different than getting something approved for a headache!  Yet most of these people, doing your paperwork, treat it as such.

You have got to be "proactive" (and polite - but assertive). 

First - call your insurance company's customer service line and get the exact department's name and fax number that your doc must use, when submitting your paperwork.  This is important, as the insurance companies tend to play games here, and will stall your order for days.
 
You have got to have your short list of personal medical issues in hand and "talk" directly with the person in your doc's office that writes up the paperwork.  Do not assume that they understand your situation.  Your file may be thick enough that they will not read it all - and they will leave out something important to your success of being approved.  Many prior illnesses will disqualify you for the cheaper - dangerous treatments. Use your medical history to your advantage. It's your life!

You then have to ask that person in your doc's office "when" (date and time of day)  she/he is going to fax the paperwork and to "what" fax number and department at your insurance company.  If the department and/or fax number differs from what the insurance company told you - correct her/him.  Doc's offices get this wrong ALL THE TIME, and the insurance company will stall your order to the legal limit of the law - without letting you know.

On the date your doc's office told you, and 30 minutes after the time they told you - call them and ask them if they have faxed your file to the insurance company yet.

Follow-up, Follow-up, Follow-up! And be polite, but assertively proactive.  Remember, this means more to you than it does to them. It's your life.

If they haven't done it yet, ask them why, and when they plan on faxing it. Explain to them that you want this info because you are going to follow-up with the insurance company and need to know that they have sent it before you call the company.  Ask her/him to call you just as soon as it's faxed so you can begin the follow-up process with the insurance company.

Once the insurance company has the info, give it 15 - 30 minutes and then call customer service.  Tell them that your file is there and ask them to check and verify it for you.  If they play the "wrong fax or department" game with you, ask him/her to call your doc's office and straighten it out for you.  Have your contact's name & direct number ready, and get ready to be on hold a while.

These steps are important, as these people play games everyday. Everyday they stall you - it's money in their pocket.

Be polite and be proactive - it's your life! 

You can also usually check on your insurance companies web pages what their criteria is for approving Harvoni.  Many companies have a Stage 2 criteria, but "try" for Stage 3.  Check it out, as it can help you in the long run!

[BattleTheBeast]

Great job explaining Roger! You are so right, we have to be persistent and proactive but not forget to be polite!

I know it can be frustrating but you are normally speaking to someone who "works there" and they are more likely to do all they can for you if you are polite vs. any other approach.

Mel