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Author Topic: Medicare Advantage Plans do they cover cost of treatment?  (Read 3172 times)

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Offline kim77

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Medicare Advantage Plans do they cover cost of treatment?
« on: October 19, 2018, 06:33:36 pm »
I have another post on here with my story, but I found out the end of Sept. this year I have Hep C. Probably from a accident and blood transfusions before they tested blood. I am currently awaiting the results of my liver biopsy to determine how much damage there is. Ultrasound did show scarring. I currently have Medicare part A&B with no prescription plan. Today I called the 1-800-medicare number and out of the 7 Medicare Advantage plans available to me, none of them cover the Harvoni my Dr. wants to prescribe. At my appointment with the specialist she told me the Advantage plans were good at approving treatment. I am confused and kind of lost at what I should do. Please help...
Kim77

Offline dragonslayer

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #1 on: October 19, 2018, 10:04:52 pm »
Back in 2014 when I was treated with Harvoni, my Medicare Advantage plan covered it.
Paul

DX 2008
Started Harvoni 11/26/14 for 8 wks
Completed 8 wks Harvoni 01/20/15
EOT RNA Quant result:  Detected 29
7.5 wk post tx: Detected < LLOQ(12)
11 wk post tx: UNDETECTED SVR12
24 wk post tx: UNDETECTED SVR24; AST 26; ALT 22; ALP 73
48 wk post tx: UNDETECTED SVR48; AST 18; ALT 18; ALP 70
GT 1a
vl 2.4mil
2008 bpx: Stage&Grade 0
2013 bpx: Stage&Grade: 0-1
IL28B: TT
likely infected early '70s

Offline kim77

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #2 on: October 19, 2018, 10:31:42 pm »
Good to hear. I tried to call the specialist today but she was working at the hospital. But, I know her assistant told me the Advantage Plans were really good. I am wondering if the Medicare lady knows what she is talking about. She said it would be $31,000 and gave me a phone number to a financial support number. When I called they said in order to get funds I would have to have a plan that covers some of the drug cost. I am going to call on Monday and see if my Dr. can enlighten me.
Kim77

Offline Lynn K

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  • Get tested, get treated, get cured, fight Hep c!
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline kim77

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #4 on: October 20, 2018, 09:27:13 am »
Thank You, Lynn. When I enter Harvoni it says it is covered. I have no idea why that lady told me it wasn't. I was in tears after our conversation....
Kim77

Offline Lynn K

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #5 on: October 20, 2018, 12:07:01 pm »
Maybe try calling again see if you get someone different and ask them about what you learned using the Medicare website.

Unfortunately not everyone who answers these calls is as well informed as they should be.
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline kim77

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  • Posts: 19
Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #6 on: October 22, 2018, 10:16:09 pm »
My Dr. is out of the office until Wednesday. I had another DR. from her clinic call me today with the biopsy results. He didn't really tell me much except I have Cirrhosis. I asked about what stage and he said cirrhosis is stage 4, there are no other stages. This contradicts what I have read. Guess, I still have to wait until Weds. to find anything else out. Feeling pretty down right now....
Kim77

Offline Lynn K

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #7 on: October 22, 2018, 10:53:40 pm »
Basically yes cirrhosis is end stage liver disease in that there is no higher level of liver damage. Cirrhosis equates to fibrosis level F4.

There are further definitions of cirrhosis with compensated cirrhosis where the liver is able to compensate for its damage and still perform its important functions and decompensated cirrhosis where the liver is damaged to the point that it can no longer perform its functions and symptoms of liver failure begin to occur.

I have seen other pages that breakdown the differing stages of cirrhosis based on symptoms but that is a different discussion.

But yeah either you have cirrhosis or you don’t you can’t have a little bit of cirrhosis. But you can have compensated cirrhosis and decompensated cirrhosis.
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline Lynn K

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #8 on: October 22, 2018, 10:58:45 pm »
Here is a good article about how the worsening levels of cirrhosis from compensated to decompensated are broken down.

If you don’t have symptoms you would be considered compensated. Common early symptoms are lower leg edema and a low platelet count. Also developing esophageal varicies would be a common early sign of the beginnings of decompensation.

https://www.livestrong.com/article/240024-what-are-the-4-stages-of-cirrhosis/
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline kim77

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  • Posts: 19
Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #9 on: October 22, 2018, 11:28:37 pm »
My platelet count was 115, just below. And I do have swelling in my ankle, but I have also walked with one leg on crutches my whole life and have lots of arthritis in my knee and ankle. (2 knee surgeries) so I always thought the swelling was a result of the arthritis. Thank you for the article:) I know the ultrasound said compensated.
Kim77

Offline Lynn K

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #10 on: October 23, 2018, 01:13:28 am »
Minimum normal for platelets is 150 but 115 isn’t scary low. If a patient is as low as I believe 50 they might require a transfusion of platelets. Before I was treated my platelets were around 80 to 90 range. After treatment they rose a little to around 110 so some improvement.

Having a low platelet count could be an indication of some portal hypertension. On your ultrasound did they say anything about your spleen being enlarged? Portal hypertension causes the spleen to enlarge and sequester platelets which is why platelets counts are lowered in cirrhosis.

Really the definition of stage of cirrhosis is on the basis of symptoms. A ultrasound can’t really differentiate between phase of cirrhosis as far as I’m aware.

Did they note any ascities on the ultrasound? I have had the comment of a small amount of ascities showing up on my previous ultrasounds but the last few since I was cured they have not remarked about any ascities being present.

Another test you may have to do is an upper endoscopy to check for the presence of esophageal varices.

Edema would be in both lower legs and feet. Especially pitting edema could be associated with cirrhosis but having your existing leg problems makes that more difficult to discern.
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline kim77

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  • Posts: 19
Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #11 on: October 23, 2018, 10:13:28 am »
 Abnormal liver enzymes [R74.8 (ICD-10-CM)]; Nonspecific
elevation of levels of transaminase and lactic acid dehydrogenase
(LDH)  [R74.0 (ICD-10-CM)].
 
COMPARISON: None.
 
FINDINGS: Multiple transverse and longitudinal grayscale and color
Doppler ultrasound images of the right upper quadrant were acquired.
The liver is enlarged, measuring 20.7 cm in length. Liver contour is
nodular and hepatic parenchyma has coarsened echotexture. No discrete
liver lesion or intrahepatic biliary ductal dilatation. The
gallbladder is surgically absent. The common duct measures 4.5 mm in
diameter at the level of the porta hepatis, within normal limits.
Doppler evaluation of the main portal vein demonstrates normal
directional flow and spectral waveforms. The IVC is patent. The
visualized portions of the pancreas are normal. The right kidney
measures 11.4 cm in length and has normal cortical thickness and
echogenicity. No renal mass, hydronephrosis, shadowing stone or
perinephric fluid. No dilated ureter is visualized. No free fluid in
the right upper quadrant.
 
 
IMPRESSION:
1. Findings are compatible with hepatic cirrhosis. No discrete liver
lesion.
2. Status post cholecystectomy.
 
Kim77

Offline Lynn K

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #12 on: October 23, 2018, 03:31:42 pm »
In general an ultrasound isn’t to diagnosis cirrhosis but to confirm diagnosis by other testing like Fibroscan, fibrosure or biopsy.

My ultrasounds that I have every 6 months look similar except the cause is history of hep c
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline kim77

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  • Posts: 19
Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #13 on: October 23, 2018, 06:41:38 pm »
The biopsy did say cirrhosis. I just don't know how bad because my Dr. is out of town. I am a amputee so edema is only in the one foot. :) I probably contracted when I lost my leg as a child. My DR. will be in her office tomorrow, I will be calling to get more detailed results from the biopsy.
Kim77

Offline Lynn K

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #14 on: October 23, 2018, 08:20:15 pm »
How bad is entirely based on symptoms as described in the link I sent. If you don’t have any symptoms you are in better shape than someone with symptoms.

Having cirrhosis is not good but if you don’t have symptoms and can stop the cause of your liver damage you have a good prognosis. For those of us with cirrhosis the plan is to live as healthy as we can and to avoid dying from liver disease.

With cure of hep c it is even possible you may have some regression of liver damage. They are saying about a 50/50 chance but that entirely depends on existing liver damage.

For someone with very advanced liver disease suffering from significant ascities, hepatic encephalopathy and having bleeding esophageal varicies even with cure they would still require a liver transplant to survive. But if compensated and hep c cured with care we can likely live our full life span.

So far I have been living with cirrhosis for almost 11 years. Still working full time at 60 and in fact in training for a new job currently.

With curing hep c the future is so bright I gotta wear shades 8)
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline kim77

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  • Posts: 19
Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #15 on: October 23, 2018, 10:27:44 pm »
I know I am overthinking everything. I just feel like I was given a death sentence, and the fact the Dr. who called had so little info to offer me has left me with questions. You did make me feel better knowing that I still have a chance at a long life. I am 41 and a mom of 3,  my daughter is only 11, my youngest son is 15, and my oldest is 20. I need to be here for them. My symptoms aren't too bad, but I must say I haven't felt good for a while now. The worse is the fatigue, I don't nap often but I find myself dozing off a lot lately and absolutely no energy. Some leg edema, not sure what from though. Mild pain in my right side.
Kim77

Offline Lynn K

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #16 on: October 24, 2018, 08:15:37 am »
You don’t have an expiration date believe it. Edema goes up both legs more than just the ankle and foot area so it is likely from your existing issues. Being tired a lot is the single most common symptom reported by people with hep c.

I learned I had cirrhosis 2 months before my 50th birthday. I went to Hawaii to celebrate my big 50 but I will admit at the time I didn’t feel much like celebrating. This year I just had a big party for my 60th.

Eat healthy, get your flu shots, follow your doctors advice, and get some exercise. You will be around for a long time
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline kim77

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  • Posts: 19
Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #17 on: October 24, 2018, 11:26:27 am »
Thank You, Lynn :)
Kim77

Offline kim77

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  • Posts: 19
Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #18 on: November 07, 2018, 10:48:47 am »
IMPRESSION:
This is the liver biopsy impressions,
1. Successful CT-guided liver biopsy with monitored conscious
sedation.
2. Grossly cirrhotic appearing liver. Splenomegaly. Nonspecific mild
upper abdominal lymphadenopathy, possibly due to liver disease and/or
hepatitis C.
3. Bilateral nephrolithiasis.
This is the patology report,
These fibrous bands containing lymphocytic inflammation are highlighted on
trichrome stain. The portal tracts contain a minimal lymphocytic infiltrate
with very focal interface activity. The interlobular bile ducts are intact
and free of inflammation. The lobules are also free of inflammation. The
fibrotic bands also contain a prominent ductular reaction. The reticulin
framework is intact. Iron stain shows no incre
ase in deposition. PASW is
positive in scattered macrophages, but does not demonstrate
intracytoplasmic globules and hepatocytes. In summary, these findings are
consistent with the patient's history of chronic hepatitis C infection.
This corresponds to a Batts Ludwig grade 1, stage 4.
Kim77

Offline Lynn K

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Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #19 on: November 07, 2018, 11:46:27 am »
Found this:
“Batts-Ludwig system
Uses five categories (0 to 4) separately for both grade and stage (Am J Surg Pathol 1995;19:1409)
Grade is determined by evaluation of degree of interface activity, lobular inflammation and necrosis
Stage is scored from 0 (no fibrosis) to 4 (cirrhosis)
It provides a pictorial description of each grade and stage of the disease”

So grade 1 is minimal inflamation. Stage 4 is by definition cirrhosis as the report states.

Very similar to my January 2008 liver biopsy except I had more inflamation activity as I recall.
Genotype 1a
1978 contracted, 1990 Dx
1995 Intron A failed
2001 Interferon Riba null response
2003 Pegintron Riba trial med null response
2008 F4 Cirrhosis Bx
2014 12 week Sov/Oly relapse
10/14 fibroscan 27 PLT 96
2014 24 weeks Harvoni 15 weeks Riba
5/4/15 EOT not detected, ALT 21, AST 20
4 week post not detected, ALT 26, AST 28
12 week post NOT DETECTED (07/27/15)
ALT 29, AST 27 PLT 92
24 week post NOT DETECTED! (10/19/15)
44 weeks (3/11/16)  fibroscan 33, PLT 111, HCV NOT DETECTED!
I AM FREE!

Offline kim77

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  • Posts: 19
Re: Medicare Advantage Plans do they cover cost of treatment?
« Reply #20 on: November 07, 2018, 03:18:40 pm »
Yes, that is what I have read also. I am ok with the results. I was so afraid it was going to say I had cancer or that I was in a much more advanced stage. lol. As you can tell I tend to think the worst sometimes. I of course am not happy I have cirrhosis but atleast it is considered grade 1. Makes me feel a little more at ease. Now if January 1st can get here so my insurance can take affect and I can get treated.
Kim77

 


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