Denied Hepatitis C Treatment? Here is How to Fight Back

[lporterrn]

Hi - A few people have requested info about how to fight denials for treatment by insurance companies. Hope this helps: http://www.hepmag.com/articles/hepatitis_c_treatment_2502_26761.shtml

The bottom line, call: Help 4 Hep 877-HELP-4-HEP (877-435-7443)

[morning_glory]

Lucinda,
Well written article, thank you!

Blessings,
MG

[Lynn K]

And for those with Express Scripts/Accredo writing a direct appeal to this address:

ExpressRxHelp@express-scripts.com

Has helped several people who were denied get approved I know of at least 6 people it has made the miracle happen and having meds in hand within a day over night express

[lporterrn]

Fantastic Lynn!

[morning_glory]

Lynn,
I don't feel very confident in writing my own appeal. I was denied Harvoni, due to not meeting Express Scripts / Acreedo's "numbers", etc.

I've had HCV for 40+ years.
Do you have any advice, on the best approach, in this situation?

My numbers:
Liver, Core Biopsy (6/2004) -
    Chronic hepatitis consistent with hepatitis C
    Inflammatory Activity Grade  1-2 (portal and lobular chronic inflammation with focal mild limiting plate necrosis)
    Fibrosis Stage 1-2 (mild portal and focal periportal fibrosis)
    Mild to moderate macrovesicular steatosis

Most recent Bloodwork results (2014) -
    Chronic hepatitis C without mention of hepatic coma
    HCV Genotype - 1a
    Hepatitis C Quantitation - 436,120 IU/ml
    AST - 34
    ALT - 41
    HCV FibroSURE - Fibrosis Score F0 (0.12 Stage 0 - No Fibrosis)
    Necroinflammatory Activity Score - .22 / Grade A0 - A1

Thank you,
MG

[Lynn K]

As you said you don't have cirrhosis either F3 or F4 which really in the larger view s a good thing. As a GT 1a I assume they want you to take Viekira Pak wih Riba. Unless you cannot tolerate Riba and it is counter indicated medically for example heart issues you basically from what I understand only have he option of Veikira Pak with Riba.

Is express scripts willing to approve Viekira? Can you provide express scripts any reason you cannot take Viekra Riba? I not I doubt you have a case for Harvoni with them. The made Abbie Vie preferred formulary and that is it.

There is nothing wrong with taking Viekira unless you can't handle the riba it he's good results just a bit more complicated to take.

Good luck
Lynn

[Junkyard]

Just joined the group yesterday. I got diagnosed in 2010. Probably have had hep c since 1980 ish. Went through the interferon, ribavirin and was a null responder. In 2012 went through the Telaprivera interferon riba. Cleared viral load and relapsed. That was really a downer.
My pcp has experience in this field, I got treated so generically by 2 gastro specialists I took all the forms in to my pcp filled out for the insurance and support path help.  He just had to fill out his part and fax to insurance. I will add that my company just changed to Aetna from United health care. Insurance had one question, could I take ribavirin? I called the specialist pharmacy myself and gave them the info and ask what else needed to be done. They were somewhat helpful yet they really did try to slow the process down as best they could. For instance, my doc faxed the forms to them on a Thursday, I called the next Tuesday and they did not know anything. They rep put me on hold after I told him when the doc faxed the forms to them and all of a sudden he came back and said he found it on the fax machine. He entered t,he info in the computer at that time. He also told me to call back in a few days and check. I waited until the next day and every day after that for 3 days. That was when I found out about the question for ribavirin.
My doc called the next day and backed up my info about previous treatment. From that point it took about 4 or 5 days and then approval.
Keeping the doc in line and on the ball was probably the hardest part. Aetna tried to slow down the shipping date for a few more days. Then all of a sudden they called to set up shipping. The mets got here on last Friday. I started that day, 4 days ago.
I had a mild headache for a couple of days but nothing else as far as side effects.
I am cirrotic, vl980,000 alt and ast in the 80 to 115 range. My biopsy was over 4 years ago and I have been slowing down fast the last year or so. Then came harvoni.
Insurance approved harvoni and ribavirin for 12 weeks. I just hope that is enough.
Sorry for the long reply. The point is, do not take no for the answer. No matter what. There is help in all ways and make sure that all these people know that hep c is deadly.
Get all your records and make sure you call constantly. Someone will say yes if you keep at them.
I have always been very lucky with my insurances. But I have made sure they know I pay For the insurance as well. Appeal until you get the answers you need. They are out there.
Goodluck

[Lynn K]

Hi and welcome!

About your question should you take riba?

What med are you taking Harvoni or Viekira Pak? What is your genotype? What is your fibrosis level? Do you have cirrhosis?

edit:
OK I re read you post more slowly so I see it is Harvoni and you do have cirrhosis and I figure you are GT 1

Yeah I had a heck of a fight with Express Scripts and continue to have issues with them so you have to stay on top that is for sure!

Anyway welcome again and good luck on treatment

[Mike2]

Just started Harvoni on Monday. My insurance company approved me for 8 weeks of treatment because I was never treated before. However my Dr. wants me on for 12 weeks says they will start appeal after 4weeks but they suggested I start the therapy before the appeal. Anyone have any thoughts about this.

[lovinglife]

I would get started if you have a proactive doctor who will advocate for your meds. I was told I could do 8 too bc my physical situation was similar to yours, but doc says go for 12 bc insurance aint gonna pay for this 2x. I am not sure what our moderator will say. Best to you.

[3lechit3]

My husband was diagnosed in 2013, most likely was infected for decades. Liver biopsy  in July of 2013 states : Hep C grade 3 inflammation and stage 3 fibrosis. Never was treated before.    Good GE doctor, sent him last year through a special study treatment. Virus after the treatment was undetectable, then , a month later- Hep C is back again. Doctor prescribed Harvoni.  Insurance declined, stating he has NO MEDICAL NECESSITY. He has Anthem Blue Cross & Blue Shield, PPO.. The question is: what to write in the appeal?  We have 2013 Biopsy, recent Ultrasound & abdominal CT scan but  the  last blood work was done right after the study treatment with low Virus counts. What else we might need? Please advise.