Welcome, Guest. Please login or register.
October 15, 2024, 03:20:15 pm

Login with username, password and session length


Members
Stats
  • Total Posts: 55133
  • Total Topics: 4851
  • Online Today: 224
  • Online Ever: 3061
  • (September 25, 2024, 11:40:40 pm)
Users Online
Users: 0
Guests: 143
Total: 143

Welcome

Welcome to the Hep Forums, a round-the-clock discussion area for people who have Fatty Liver Disease, Hepatitis B, C or a co-infection, their friends and family and others with questions about hepatitis and liver health. Check in frequently to read what others have to say, post your comments, and hopefully learn more about how you can reach your own health goals.

Privacy Warning: Please realize that these forums are open to all, and are fully searchable via Google and other search engines. If this concerns you, then do not use a username or avatar that are self-identifying in any way. We do not allow the deletion of anything you post in these forums, so think before you post.
  • The information shared in these forums, by moderators and members, is designed to complement, not replace, the relationship between an individual and his/her own physician.
  • All members of these forums are, by default, not considered to be licensed medical providers. If otherwise, users must clearly define themselves as such.
  • Product advertisement (including links); banners; and clinical trial, study or survey participation—is strictly prohibited by forums members unless permission has been secured from the Hep Forum Moderators.
Finished Reading This? You can collapse this or any other box on this page by clicking the symbol in each box.

Author Topic: Odd Insurance Classifications  (Read 8907 times)

0 Members and 1 Guest are viewing this topic.

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Odd Insurance Classifications
« on: March 25, 2015, 11:27:15 am »
I've been looking at my insurance pharmacy benefits online.  Very strange classifications. 

Harvoni is NP (non-preferred, requiring medical necessity) PA (prior authorization), and SP (specialty pharmacy). 

Vierka Pak is the same - NP, PA, SP

However Solvaldi is PA only.  Really?  Not even specialty pharmacy?  And since Harvoni has the least side-effects and highest cure rate - isn't it already sofosbuvir but with ledipasvir.  If ribavirin is added to a Solvaldi regime instead, it would push the price past Harvoni.

And regarding the best clinical outcome, surely the insurance company would realize that not requiring a second course of treatment would be in their financial best interest.

These numbers aren't making sense to me.  I'm over 6 weeks away from my intake appointment with a new liver doc but I want to have that first meeting be as productive as possible. 

My experience being the caregiver for my best friend who had cancer was that, despite brilliant doctors and "state of the art" treatment facilities, common sense could be overlooked with stunning regularity.  That's where an advocate comes in so I want to be well-prepared.
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline Mike

  • Member
  • Posts: 999
Re: Odd Insurance Classifications
« Reply #1 on: March 25, 2015, 12:10:09 pm »
Sovaldi by itself is not prescribed for the treatment of anything. However, when prescribed with Interferon, Olysio  and/or Ribavirin, it would require the same approval process as Harvoni or Vieka.

Best wishes, Mike
Genotype 1a
Treated 2001 with PEG and RIBV
Treated in 2014 SOL+PEG+RIBV
Cured July 2014

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Odd Insurance Classifications
« Reply #2 on: March 25, 2015, 07:55:38 pm »
If it's always part of a cocktail, then incomplete coding would make sense (in an unnecessarily vague sort of way.)

So I guess I'll find out which medications they prefer when I try to fill a prescription? Harvoni and Viekira Pak are listed very specifically as "non-preferred". 

Insurance company's Rx information page not so informative.  :-\ 
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline BubbaT

  • Member
  • Posts: 267
Re: Odd Insurance Classifications
« Reply #3 on: March 25, 2015, 09:10:48 pm »
Else, those lawyers have to get paid for something, even if it's fuzzy math and fuzzy
Cocktails!   Lol
Age 57 male
Infected late 70's
Diagnosed 95
1a, 2 prev biopsy 95, 2004
Ct 2007, 2015
Treatment Naive
F4 A3. Fibrosure/ CT 2-5-15. Ammonia 222
VL 2.2 mil.
Started Harvoni  3-3-15. 12weeks, finished 5-26-15
4 week VL undetected
12 week EOT undetected

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Odd Insurance Classifications
« Reply #4 on: March 25, 2015, 09:23:23 pm »
Ha!  Too true, Bubba. 

Reminds me of a bumpersticker I saw once - Eschew Obfuscation
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline Mike

  • Member
  • Posts: 999
Re: Odd Insurance Classifications
« Reply #5 on: March 25, 2015, 10:07:59 pm »
Yep  ;)
Genotype 1a
Treated 2001 with PEG and RIBV
Treated in 2014 SOL+PEG+RIBV
Cured July 2014

 


© 2024 Smart + Strong. All Rights Reserved.   terms of use and your privacy
Smart + Strong® is a registered trademark of CDM Publishing, LLC.