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Author Topic: denied by Prime Theraputics anyone else?  (Read 7923 times)

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Offline C-FIGHTER

  • Member
  • Posts: 43
denied by Prime Theraputics anyone else?
« on: February 25, 2015, 07:44:50 pm »
i have been denied twice now by Prime Theraputics for Harvoni. BCBS of Illinois is my insurance company. The second denial letter was identical to the first and no mention of the appeal.  When calling Prime, i was told my Dr's office knew what they were looking for.  My doctor's office has not communicated with me at all.  The doctors office uses another company to submit all the paperwork for them. No one knows anything, no one calls me,and when i try to get some answers as to what is the next step, I am told to wait for a phone call. However not when i will get that call.  It has now been a total of 6 weeks. I am frustrated not because so much i was denied, but because i am in the dark as to what is happening.  I am a healthy sick person with no fibrosis, or very little. F0-F1. I am 58 years old and probably had this virus for about 40 years.  Has anyone else had this experience? thanks for reading this.
diagnosed 2010 Hep C
genotype 1b
HCV RNA >4000000 01/13/2015
F0-F1 04/2014
Harvoni March 20 2015 - June 11 - 12 weeks

April 14-Day 26 on Harvoni- Viral Load - UD
ALT 27    AST 27

Offline pl1952

  • Member
  • Posts: 24
Re: denied by Prime Theraputics anyone else?
« Reply #1 on: February 25, 2015, 08:05:45 pm »
Hi C-Fighter,  I'm in a similar position, except my insurance is United Healthcare.  I've had Hep C for about the same length of time as you, and I'm F0-F1, little fibrosis.  I just received my 2nd denial from UHC.  My dr.'s office uses Acaria to do this paperwork, but they have been wonderful, although I made it my business to call them each Monday to follow up.  They have just filed a request for Harvoni for me through Gilead's support path now that I received my 2nd denial, and I'm waiting on this now.  I would ask your doctor's office for the name and number of the contact person at the company they use and call them to see what's going on with your case...
GT 1b
Treatment naive
2/2014:  Fibroscan 4.5
12/2014:  VL:  650,000
Started Harvoni 3/6/15
EOT: 5-28-15
9-2015:  SVR 12

Offline C-FIGHTER

  • Member
  • Posts: 43
Re: denied by Prime Theraputics anyone else?
« Reply #2 on: February 25, 2015, 08:19:23 pm »
Hi, and thank you so much for your reply.
Acaria is the company that my doctor's office uses.  I have not found them to be forth coming with information,  I do make a phone call once a week.  I was not really clear on who should be communicating with me, doctors office or Acaria.
I did just send an email to the Dr. office and waiting to hear what is going on?

I appreciate your answer.  How long has the process been for you so far?
thanks, Janice


diagnosed 2010 Hep C
genotype 1b
HCV RNA >4000000 01/13/2015
F0-F1 04/2014
Harvoni March 20 2015 - June 11 - 12 weeks

April 14-Day 26 on Harvoni- Viral Load - UD
ALT 27    AST 27

Offline Bituman

  • Member
  • Posts: 157
Re: denied by Prime Theraputics anyone else?
« Reply #3 on: February 25, 2015, 10:50:00 pm »
CF it sounds to me like the approval procedures that your doctor and Acaria are using are not right.  By contrast, I was approved for 12 weeks Harvoni in about 3 days by BCBS TX via Prime Theraputics.  But I think this was facilitated by the professionals at my health care provider, Mayo Clinic Scottsdale.  They really seem to know their way through the approval process.  FWIW my stats very similar to yours.  Maybe it's time you work with a health care provider that has some expertise at this.  My 0.02$US. 

Bob
Age = 59, male, infected likely 1975
DX 07/07 GT 1a
Biopsy 2007:  GR 1, stage 0, HAI = 2/18
Since 2007:  1.48 MM < VL < 11 MM, avg = 5.64 MM
IL28B=CT
1/26/15, AST=43, ALT=55, VL=3.59 MM
2/5 Start Harvoni 12 weeks; Treat naive
2/20 AST=29, ALT=24, VL=59
3/6 AST=29, ALT=25, VL<15
3/19 AST=24, ALT=22, VL=undet
4/3 AST=29, ALT=25, VL=undet
4/30 EOT, AST=22, ALT=20, VL=undet
5/29 EOT+4, AST=20, ALT=19, VL=undet SVR
7/24 EOT+12, AST=23, ALT=18, VL=undet SVR
10/16 EOT+24, AST=22, ALT=17, VL=undet SVR

Offline pl1952

  • Member
  • Posts: 24
Re: denied by Prime Theraputics anyone else?
« Reply #4 on: February 26, 2015, 05:36:37 pm »
Hi Ci-Fighter,  I just now received a call from Gilead Support Path that I've been accepted!  I'm beyond words!  To answer your question, beginning of January the ball starting rolling with my Doctor; from then to now, just about 2 months of waiting, 2 denials, 2 appeals.  This Monday we went to Gilead Support Path and Acaria told me it will be a wait of about 2 weeks or more.  I almost had a heart attack when Support Path called me today and said "I have good news for you".  So don't stress it -- Get the person's name at Acaria that is working on your case and get them moving with the Support Path for you.  Good luck and keep us posted!
GT 1b
Treatment naive
2/2014:  Fibroscan 4.5
12/2014:  VL:  650,000
Started Harvoni 3/6/15
EOT: 5-28-15
9-2015:  SVR 12

Offline C-FIGHTER

  • Member
  • Posts: 43
Re: denied by Prime Theraputics anyone else?
« Reply #5 on: February 26, 2015, 07:10:31 pm »
to pl1952.

 I am so so happy for you, and it makes me hopeful. I wish you a speedy SVR, from this awful debilitating virus.

 I understand there is some criteria which Gilead has  such as the household income of 100,000 or less.
I think we just may be over that here at my house, though plenty of it goes back out. It really is not a lot of money with children in the home, mortgage etc.

anything else you could tell me about that program is much appreciated.  Good Luck!!!!!
Janice
diagnosed 2010 Hep C
genotype 1b
HCV RNA >4000000 01/13/2015
F0-F1 04/2014
Harvoni March 20 2015 - June 11 - 12 weeks

April 14-Day 26 on Harvoni- Viral Load - UD
ALT 27    AST 27

Offline C-FIGHTER

  • Member
  • Posts: 43
Re: denied by Prime Theraputics anyone else?
« Reply #6 on: February 26, 2015, 07:15:24 pm »
To Bitman,

thank you for your reply to me.  my doctor's office is located in NY city, and is a teaching hospital as well.  The office is filled with plenty of patients like myself.  I was assured they know their way around the approval process. I am thinking it may just be overwhelming and I am falling through the cracks. I have been going there for a little less than a year. I will be calling there tomorrow when I get home, and hope to get some answers.  I hope to post soon to say I have been approved.  I will keep fighting.  Thank you.
diagnosed 2010 Hep C
genotype 1b
HCV RNA >4000000 01/13/2015
F0-F1 04/2014
Harvoni March 20 2015 - June 11 - 12 weeks

April 14-Day 26 on Harvoni- Viral Load - UD
ALT 27    AST 27

Offline pl1952

  • Member
  • Posts: 24
Re: denied by Prime Theraputics anyone else?
« Reply #7 on: February 26, 2015, 08:04:44 pm »
Hi Janice, just sent you some more info on PM....
GT 1b
Treatment naive
2/2014:  Fibroscan 4.5
12/2014:  VL:  650,000
Started Harvoni 3/6/15
EOT: 5-28-15
9-2015:  SVR 12

Offline Bituman

  • Member
  • Posts: 157
Re: denied by Prime Theraputics anyone else?
« Reply #8 on: February 26, 2015, 08:40:56 pm »
To Bitman,

thank you for your reply to me.  my doctor's office is located in NY city, and is a teaching hospital as well.  The office is filled with plenty of patients like myself.  I was assured they know their way around the approval process. I am thinking it may just be overwhelming and I am falling through the cracks. I have been going there for a little less than a year. I will be calling there tomorrow when I get home, and hope to get some answers.  I hope to post soon to say I have been approved.  I will keep fighting.  Thank you.

I will be hoping for your success in terms of approval.  It sounds like you are in an excellent place for treatment, but based on what you said I remain skeptical about their ability to advocate for their patients.  In fact, it sounds like they have farmed that out to someone else.  This is too important for you to fall thru the cracks!  Nevertheless, I am sure you will find a way to beat the approval process into submission.  See my affirmation below, that's you.  Good luck. 

Bob
Age = 59, male, infected likely 1975
DX 07/07 GT 1a
Biopsy 2007:  GR 1, stage 0, HAI = 2/18
Since 2007:  1.48 MM < VL < 11 MM, avg = 5.64 MM
IL28B=CT
1/26/15, AST=43, ALT=55, VL=3.59 MM
2/5 Start Harvoni 12 weeks; Treat naive
2/20 AST=29, ALT=24, VL=59
3/6 AST=29, ALT=25, VL<15
3/19 AST=24, ALT=22, VL=undet
4/3 AST=29, ALT=25, VL=undet
4/30 EOT, AST=22, ALT=20, VL=undet
5/29 EOT+4, AST=20, ALT=19, VL=undet SVR
7/24 EOT+12, AST=23, ALT=18, VL=undet SVR
10/16 EOT+24, AST=22, ALT=17, VL=undet SVR

 


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