Oregon Medicaid "FamilyCare, Inc"

[garyc]

I am 61 years old - genotype 1, non responder to interferon/ribaviran in 2010, vl 16 million, cirrhosis stage 4, infected in 1980s and diagnosed in 1995.
I am a Pastor and I have worked without a salary for 15 years operating a Christian d & a program in Oregon. I do receive housing, car, etc. as the Director of this center and had medical ins. thru my wife's work (Providence EPO Health Plan). In 20012 my wife became seriously ill and had to go on disability and SSD but we kept paying ins. at cost of $1,116/month. While on Providence ins. in April 2015 my Gastroenterologist wrote Rx for Harvoni and sent to Central Drug. Providence denied me but I could no longer afford the $1,116 mo ins. payment and when my wife went on Medicare  - starting May 1, 2015  I applied for Oregon Health Plan and was approved beginning April 27, 2015. The ins. is thru FamilyCare, Inc. They list HARVONI as PA and SP on their April 2015 drug formulary. Drs. office and pharmacy sent info for PA ( to FamilyCare (Drs office thought I should have no problem getting approved) but today I was denied citing very general reason (OAR 410-120-1200 and OAR 410-141-3020(2)) I read those OR Admin Rules and it seems there are so many loopholes that they can deny authorization for treatment to anyone. I spoke with Central Drug and the women that works on this told me not to send in the Appeal Letter that FamilyCare sent me because she is submitting for PA again and the ins. co. can say they denied authorization a 2nd time because I am awaiting an appeal. She said wait until 2nd denial and then appeal. I am stressed because I do not feel well at all and have not for the last few years. Trying to talk with gastroent. dr. is impossible as he has a ton of patients and many need hep c treatments so he has a list, when your name comes up (according to severity of illness and need for new hep c treatment) he sees you and does labs and submits prescription to pharmacy and pa to insurance. I know Oregon has really been brutal on including the new hep c treatments as part of their ins. drug formularies and have very strict caveats for pa but I was told by dr. and pharmacy I met all requirements. Does anyone know of anyone that got authorization for Harvoni thru medicaid in Oregon. It didn't matter if I was paying over $1,000 a month for insurance or on state insurance for $0 - I was denied authorization from both types ins. Anyone have any ideas?  Sorry I was so long but I am so worried and tired - I just want to try the new treatment. INTERF/RIB almost killed me - I was on over 45 wks in 2010 and went from vl 6 million to 2,000 but am now up to 16 million. Thanks for listening garyc

[lporterrn]

Hi Gary,
This is very typical, and most people win after a few denials. There is lots of help out there, and it looks like now you just wait. This might be a good time to check out the parable in Luke 18  - It sums up how this all works with the insurance company.

[garyc]

Thank you for your reply. It was good to be reminded of that. I know that I have help that cannot be seen in the natural but it has been such a long wait for a good treatment that I grew weary. You helped recharge my inner man with your reminder of Luke 18 - I will continue to persist.
I have not read anyone's post regarding medicaid and was wondering if anyone in Oregon had been approved for Harvoni treatment. I do know that just about everyone who is on treatment or finished treatment wrote they received denials from insurance before they were approved.
Thank you for your words.  I would like to hear from anyone on state insurance awaiting or receiving approval for one of the new hep c treatments.  Have a great weekend gary

[garyc]

Thank you for your reply. It was good to be reminded of that. I know that I have help that cannot be seen in the natural but it has been such a long wait for a good treatment that I grew weary. You helped recharge my inner man with your reminder of Luke 18 - I will continue to persist.
I have not read anyone's post regarding medicaid and was wondering if anyone in Oregon had been approved for Harvoni treatment. I do know that just about everyone who is on treatment or finished treatment wrote they received denials from insurance before they were approved.
Thank you for your words.  I would like to hear from anyone on state insurance awaiting or receiving approval for one of the new hep c treatments.  Have a great weekend gary

[lporterrn]

I know one person who is on it, and she was denied Harvoni but was approved for Viekira. Her doc is appealing.

Right now, several states are rewriting their hep C guidelines, making them more generous. I believe they are doing this in part because of deals the pharma companies are making, and in part to avoid litigation, which is starting to happen across the country.

Important to keep in mind that there are patient assistance programs, so if you are denied, you are not out of options.