Author Topic: Anthem 2016 Tx Criteria (Read 11728 times)

Coach Mike · « **on:** January 12, 2016, 06:23:22 pm »

Anthem's Criteria for Harvoni approval.
I am not sure what this means in English.

https://www.anthem.com/provider/noapplication/f0/s0/t0/pw_e225443.pdf

Coach Mike

FutureThinker · « **Reply #1 on:** January 12, 2016, 08:33:07 pm »

Great find, CM!! But is appears to still use fibrosis stage, just in different language?? FT

Coach Mike · « **Reply #2 on:** January 12, 2016, 08:40:45 pm »

Yeah, Thats what it looks like. Can you have a "compensated" liver disease and not have cirrhosis?
CM

FutureThinker · « **Reply #3 on:** January 12, 2016, 08:44:41 pm »

We need some input from our moderators on the wording of this document. I was just reading another topic re: insurance and all I can say is, as of today, as I await the state's IMR decision over the next 30+ days is that I am just sooooo grateful that there are options now: several trials going on not too far from me, generics now available, even if I am still a bit afraid of that route, new drugs in the pipeline....... at least there is HOPE!! FT

Coach Mike · « **Reply #4 on:** January 12, 2016, 08:57:29 pm »

I think the IMR will favor you. Anyway you cut it, you still have a potentially life-threatening disease for which there is a cure.
I wouldn't be concerned about Dr. Freeman's REDEMPTION trials. The medicines are tested and guaranteed to arrive. Kingswood and West Lindfield Compounding Pharmacies in Australia will also ship if you send them your prescription.
CM

Lynn K · « **Reply #5 on:** January 13, 2016, 12:17:09 am »

To me it appears as far as cirrhosis status they are defining different treatments for those with compensated cirrhosis, those with or without compensated cirrhosis and treatment for those with decompensated cirrhosis.

So the "without compensated cirrhosis" means for those who don't have cirrhosis. Then "with or without compensated cirrhosis" wold be the recommended treatment for those who do not have cirrhosis or those with compensated cirrhosis.

They recommend "treatment-naïve or -experienced, post liver allograft transplant with decompensated cirrhosis" 12 weeks of Harvoni with Ribavirin.

With liver damage we can have compensated liver disease whether or not we have cirrhosis. For example someone with F2 fibrosis their liver is able to compensate for the level of damage all the way up to F4 compensated cirrhosis. I guess that is what they are going for but I can see how it would be confusing.

Ah found it see page 3:

Compensated Liver Disease:
According to the American Association for the Study of Liver Diseases (AASLD, 2009, 2015),
the specific criteria for compensated liver disease include all of the following: a total bilirubin;
serum albumin; prothrombin time/INR; presence of ascites; and presence of hepatic
encephalopathy. However, these criteria do not establish a comprehensive definition of
compensated liver disease. The AASLD guidance refers to compensated liver disease as
Class A based on the Child Pugh-Turcotte (CPT) classification scoring system.

So anyone with liver disease that has not progressed would be a child A and thus considered compensated Liver Disease

Coach Mike · « **Reply #6 on:** January 13, 2016, 05:25:48 am »

Thanks Lynn,
So, they took away the old F-score restrictions?
CM

Coach Mike · « **Reply #7 on:** January 13, 2016, 05:57:46 am »

Care Mark's PA criteria:

http://www.caremark.com/portal/asset/FEP_Criteria_Harvoni.pdf

CM

Coach Mike · « **Reply #8 on:** January 13, 2016, 07:20:06 am »

Lynn,
Isn't Child-Pugh an indication of the severity of cirrhosis? I mean, can you have be a "Child A" and not be cirrhotic?

If that's the case, are they are effectively restricting treatment to F-4 patients?
CM

Philadelphia · « **Reply #9 on:** January 13, 2016, 10:59:53 am »

I thought F4 indicated cirrhosis and Child-Pugh was the cirrhosis continuum, from A to C. But I could be wrong and I sure someone likeLucinda will have the right answer.

lporterrn · « **Reply #10 on:** January 13, 2016, 11:10:13 am »

First, the 2 insurance documents in this thread open the door to treating F0-F4. The only restrictions they continue to have that aren't consistent with the HCV guidelines http://www.hcvguidelines.org/ are those pertaining to drug and alcohol use. However, there are ways to work around that.

RE Child-Pugh - technically it could be applied to everyone, but its only clinically significant when someone is cirrhotic. In the case of the Anthem criteria, they are using to determine which treatment is appropriate, and not using it to exclude earlier fibrosis stages.

lporterrn · « **Reply #11 on:** January 13, 2016, 11:17:33 am »

About the Child-Pugh, here's another way of looking at it:
You could apply it to anyone, but why? Just like you could apply the Glasgow Coma Scale to assess my consciousness level, but given that I am sitting at my computer rather than in a neuro ward, you wouldn't.
So, if a patient presents with obvious cirrhosis, than a C-P score is warranted.

Philadelphia · « **Reply #12 on:** January 13, 2016, 11:39:29 am »

I think there are times when you could apply that coma scale to me when I'm sitting at my computer ...

FutureThinker · « **Reply #13 on:** January 13, 2016, 11:54:50 am »

Philly, thanks for the laugh, God knows I need one!! So it appears that while Anthem is overall opening up their criteria for coverage, they are using language that doesn't make it readily clear as to their intention.

I unfortunately don't have Anthem, so still hoping/praying the IMR works!! So much valuable info on this forum, thanks to all of you, really appreciate it. FT

lporterrn · « **Reply #14 on:** January 13, 2016, 12:27:39 pm »

Here is Aetna's plan - bless them they don't say a word about substance use. They have always been ahead of the curve with the newest hep C meds. However, I have no idea why they include Victrelis - someone needs to update that,. http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html

Lynn K · « **Reply #15 on:** January 13, 2016, 03:28:00 pm »

Yes Child Pugh is used to stage cirrhosis as well as the MELD score. But as Lucinda said anyone could be evaluated in the scale and obviously if you don't have cirrhosis you would score as child A.

They did say without compensated cirrhosis as well on certain regimens so they are not cutting out those who are not F4 as I read this.

But yeah could they have made this harder to understand what they mean lol

Cirrhosis without hepatic coma is my official diagnosis good to officially know I am not in a coma

Maybe the Matrix?

FutureThinker · « **Reply #16 on:** January 13, 2016, 04:38:49 pm »

Lynn, thanks for the laugh and we are so glad you are NOT in a coma!! FT

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Author Topic: Anthem 2016 Tx Criteria (Read 11728 times)