Advice on how to appeal with ExpressScrips for Harvoni?

[New York Girl]

Hi, this is my first time on the forum. I have United Healthcare insurance, which is partnered with Express Scrips/Accredo for drugs. They will only approve Viekera with ribavirin, not Harvoni. My doctor has tried one appeal, which was rejected, and I am planning on appealing that denial with my own letter. I'm wondering if anyone has had any success with this process, and if so, could offer any advice. I am unwilling to risk the side effects of ribavirin. I had colon cancer 7 years ago and underwent a life-threatening course of chemo; it was not supposed to be so severe, but I had very strong, unusual, and devastating side effects. The treatment eventually had to be stopped two rounds before the end because the doctor thought I would not survive it. I developed PTSD as a result. The side effects of ribavirin are similar to some of those I experienced in chemo, and I am terrified of going through that again. I cannot stop working for the 3 months of treatment, and can't imagine how I could get through the regimen. I've been reading accounts by people on this forum and it is heartbreaking. It infuriates me that decisions about medication are being made on financial, not medical grounds, and that I might have to take a medication that is not what my doctor or I want just because my insurance company has chosen to partner with a company that makes an inferior drug. Can anyone offer any help? Many thanks to all of you for sharing your stories.

[Tpropane]

You need to plead for your doctor to get on board and help you. I was denied 3 times... plug away and send labs. It is similar to a loan modification. THey keep asking for your biopsy, lab, blood test, sonogram. You need these results to fight the fight.
Tpropane

[New York Girl]

Were you treatment naive before appealing? Express Scrips denied my doctor's first appeal on that basis; say they only approve Harvoni if Viekera fails. I think it is outrageous, and I will definitely continue to fight. Just wondering if anyone has any specific strategies that might work?

[lolacme]

New York Girl,
I experienced the same thing with express scripts/accredo. My dr. had went so far as to rewrite my prescription for the Viekira Pak when Carol, a lady from my Dr.s office, said she had gotten my Harvoni approved. I had written my own letter in the very beginning when asking for Harvoni and they told me it required a pre authorization and they sent the pre authorization request to my Drs. office which Carol filled out. They denied but she kept calling them. I asked her how she finally got it approved and she told me she was just able to get someone on a good day. She got angry with someone and asked to speak with a supervisor. The pharmacist supervisor said I met the qualifications and gave the prior authorization which they then sent to accredo. I am F3 stage 2 and I have attempted treatment with interferon and ribaviran before. Had a reaction to ribaviran requiring 4 units of blood and I told them that in my letter. Keep pushing. I don't think Viekira is an inferior drug but it does interact with more meds, has more side effects and comes with Ribaviran but it's success rate is equally as good as Harvoni. I blocks viral replication in 4 ways.

[New York Girl]

lolacme, thanks so much for your input. I think that the fact that you had a prior treatment that failed is the key - and so sorry you had to go through that in order to get Harvoni, which is clearly the gold standard since it works without ribavitin, and which all insurance should pay for. It's just so frustrating to have our lives decided by the vagaries of big pharmaceutical companies! Good luck!