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Author Topic: Insurance Denied  (Read 1000 times)

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Offline Sage

  • Member
  • Posts: 15
Insurance Denied
« on: May 25, 2019, 07:02:02 pm »
Was supposed to start Mavyret yesterday. I have been trying for several years to get treated for this disease and my HMO doctors denied me every time. Finally on medicare and found a Dr. to treat me and now the insurance denied me saying I have to see a specialist. This Dr. has been treating people on other insurance plans without denials. They will send a letter and try to get approval so now it’s wait some more. Errrg! So apprehensive about the side effects and being denied that I hardly sleep. Anyone else being treated by a regular Dr? Do you think I will have to or would I be better off seeing a specialist?
1a
F2
Viral load 3,260,000

Thyroid Cancer
Basal Cell Cancer
Breast Cancer

Offline LindaBalz

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  • Posts: 83
    • FB
Re: Insurance Denied
« Reply #1 on: May 26, 2019, 08:57:13 am »
Don't give up! I was denied by BCBS at first because of a clerical error, which was quickly resolved. Then I got help with the copay which was 250. and it went down to 5. a month. Now I am cured. Its worth the fight!

Linda
LB

Offline badbradley

  • Member
  • Posts: 291
Re: Insurance Denied
« Reply #2 on: May 26, 2019, 10:43:52 am »

Was supposed to start Mavyret yesterday. I have been trying for several years to get treated for this disease and my HMO doctors denied me every time. Finally on medicare and found a Dr. to treat me and now the insurance denied me saying I have to see a specialist. This Dr. has been treating people on other insurance plans without denials. They will send a letter and try to get approval so now it’s wait some more. Errrg! So apprehensive about the side effects and being denied that I hardly sleep. Anyone else being treated by a regular Dr? Do you think I will have to or would I be better off seeing a specialist?
Call to Action: Physicians Needed to Alleviate HCV Treatment Restrictions

   Most states require prescribing by specialists — generally, gastroenterologists, hepatologists and infectious disease specialists — or prescribing in consultation with a specialist.
     Serving as gatekeepers puts specialist in a very difficult situation, as without them, in most states, no one living with HCV can be treated.
...there are many health care providers who have significant experience treating patients with HCV who do not fall into the specialist category. By making specialists the gatekeeper to care, state Medicaid programs have created a bottleneck that saves them money by keeping individuals from receiving the curative HCV treatment they need.
   There is clear a solution to this gatekeeping problem. Specialists could play a leading role in a successful effort to end unfair and discriminatory treatment access restrictions, including the prescriber limitations in their state’s Medicaid programs. In particular, specialists could make it clear to state policymakers that these restrictions are unjustified, defy established treatment standards and violate federal Medicaid law. The restrictions also often violate state law.

https://www.healio.com/hepatology/hepatitis-c/news/print/hcv-next/%7B69c3e91a-8f3c-47a2-8b9c-e2b97b59045c%7D/call-to-action-physicians-needed-to-alleviate-hcv-treatment-restrictions

Geno 1a
Sov/Oly 12wks - relapse
Har/Riba 12wks
Alt-16  Ast-17 SVR - 12
Alt-15  Ast-14 SVR - 24

Offline Lynn K

  • Global Moderator
  • Member
  • Posts: 4,255
  • Get tested, get treated, get cured, fight Hep c!
Re: Insurance Denied
« Reply #3 on: May 26, 2019, 01:57:30 pm »
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 Nina Mae

  • Member
  • Posts: 50
Re: Insurance Denied
« Reply #4 on: May 28, 2019, 12:51:47 am »
That's a great link Lynn K provided.

Your dr may be able to appeal the decision also, I think.  Don't be scared, you'll be fine. 

I'm up here in Canada and I go through a specialist but that's what's required up here.

Good luck!  I was on Epclusa and the side effects, for me, were very minimal.  I've heard similar stories from other folks who are on Mavyret and they mostly seem to tolerate it well.

If you've had to endure chemo and/or radiation, this is so much less invasive.  Trust me, I went through that too.

Chin up always   :)
Dx'ed HVC and cirrhosis Nov, 2018
GT: 1a; TN; F4-44
Started Epclusa and Ribavirin on Mar 2019

Offline Sage

  • Member
  • Posts: 15
Re: Insurance Denied
« Reply #5 on: May 28, 2019, 01:03:56 pm »
Thank you all for the support and information. My Dr. has been treating people on medicaid but I have medicare. There was a consult with a specialist and a letter written to send to my insurance but the letter didn’t get sent until I showed up with an urgent problem on the Monday before. Someone just didn’t do their job, her name is Misty and she is afraid to speak with me now. So I intend to become such a pest that they make sure my needs are met so I go away, lol. I am the first person they have treated on medicare so we are learning together.
If the online pharmacy is correct my co pay will be around $2500 for 4 weeks of Mavyret. I also have a grant from Healthwell Foundation to pay for my copay. I can’t get the copay coupon with medicare. I found the foundations by calling a number found on the drug companies website abbvie gave me names of 5 foundations.
Looking back now I am glad I didn’t start Mavyret just before a 3 day weekend because I don’t know what side effects I might get. With chemo the only side effects I didn’t get was death and that’s only because I refused to complete the rounds. My liver just couldn’t clear all that poison. That’s why I want this virus out of me.
Thanks for letting me blab and blubber.
1a
F2
Viral load 3,260,000

Thyroid Cancer
Basal Cell Cancer
Breast Cancer

Offline Nina Mae

  • Member
  • Posts: 50
Re: Insurance Denied
« Reply #6 on: May 28, 2019, 04:10:17 pm »
Hi Sage,

I feel for you.  You can blab and blubber away here!  I do it all the time and you won't find more compassionate people than you will here.

Remember how we had to be our own advocates with our cancer(s)?  Well, it's the same thing with this; continue being vigilant with everything.  They mean no harm but we have no time for incompetency either.  Good catch, Sage re: 'Misty'. 

I just completed my tx (Epclusa and Ribavirin) on May 23 (EOT).  I'm waiting to hear what the HCV RNA test results.  The test was done and it feels like an eternity to get the results!

My point is this:  since my own cancer and all that's involved, I, too, was terrified to start HCV tx.  Trust me, this is not like anything you went through with chemo et al.

The new drugs that are used to cure HCV now are so much less invasive than what many of this forum's members endured.  I, for one, am grateful for the new meds and I am humbled by those warriors before us who led the way.

It seems you're navigating it all well and by looking at your signature, I know you're gonna be great! 

Keep your chin up!  You'll get your meds, you'll get treated and you'll be cured!

Nina~
Dx'ed HVC and cirrhosis Nov, 2018
GT: 1a; TN; F4-44
Started Epclusa and Ribavirin on Mar 2019

Offline Sage

  • Member
  • Posts: 15
Re: Insurance Denied
« Reply #7 on: May 28, 2019, 06:50:06 pm »
Just got a call from my supplemental insurance company to let me know they got the letter from my Dr. I guess I will know by the end of the week if there will be a final denial or not. They said my Dr. is a trained hepatologist but is practicing in family practice.
1a
F2
Viral load 3,260,000

Thyroid Cancer
Basal Cell Cancer
Breast Cancer

Offline lporterrn

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  • LucindaPorterRN
    • LucindaPorterRN
Re: Insurance Denied
« Reply #8 on: May 28, 2019, 07:10:50 pm »
I have a few more tips, but rather than inundate you with them, let's see what happens. Hopefully you won't need this tips. As for your co-pay - most likely that can get dropped to a more manageable $.

As for your question re seeing a specialist - as was said, some insurers require the Rx to come from a specialist. Also, if you have cirrhosis, you will need to see a specialist since successful hep C treatment does not always mean your cirrhosis is treated. You will need to be followed post-treatment if you have cirrhosis. 
Lucinda Porter, RN
1988 Contracted HCV
1997 Interferon nonresponder
2003 PEG + ribavirin responder-relapser
2013 Cured (Harvoni + ribavirin clinical trial)
http://blogs.hepmag.com/lucindakporter/

Offline Sage

  • Member
  • Posts: 15
Re: Insurance Denied
« Reply #9 on: May 28, 2019, 08:14:05 pm »
hi Iporterrn

I would welcome all the tips I can get.

F2 fibrosis is what I have and AST 64 ALT 81 and usually rising.

My grant from Healthwell foundation should more than cover my copay.
1a
F2
Viral load 3,260,000

Thyroid Cancer
Basal Cell Cancer
Breast Cancer

Offline Lynn K

  • Global Moderator
  • Member
  • Posts: 4,255
  • Get tested, get treated, get cured, fight Hep c!
Re: Insurance Denied
« Reply #10 on: May 28, 2019, 10:27:55 pm »
Well that is one piece of goodness you don’t have a fibrosis score ofF4 so you don’t have cirrhosis

ALT and AST are commonly slightly elevated with hep c. Once you start treatment your liver enzyme scores will very likely go into normal range with your first on treatment blood test

Hope you hear good news soon that you are approved
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 DelGan

  • Newbie
  • Posts: 1
Re: Insurance Denied
« Reply #11 on: May 29, 2019, 09:30:36 am »
As for your question re seeing a specialist - as was said, some insurers require the Rx to come from a specialist. Also, if you have cirrhosis, you will need to see a specialist since successful hep C treatment does not always mean your cirrhosis is treated. You will need to be followed post-treatment if you have cirrhosis.

I did not know this. They really make us jump through all kinds of hoops, don't they? Thanks for the insights.

Offline lporterrn

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  • LucindaPorterRN
    • LucindaPorterRN
Re: Insurance Denied
« Reply #12 on: May 29, 2019, 11:54:38 am »
Actually, it looks like you are covered - Healthwell will help you get through this. And fabulous on the F2 - it's reasonable to expect a shiny new liver when you are done with this (assuming you don't drink, have fatty liver, or abuse it with stuff it doesn't like)
Lucinda Porter, RN
1988 Contracted HCV
1997 Interferon nonresponder
2003 PEG + ribavirin responder-relapser
2013 Cured (Harvoni + ribavirin clinical trial)
http://blogs.hepmag.com/lucindakporter/

Offline Nina Mae

  • Member
  • Posts: 50
Re: Insurance Denied
« Reply #13 on: May 29, 2019, 05:50:05 pm »
Sage,

I told you!  These ppl on here are so awesome! 

And isn't it so excellent you don't have cirrhosis?  That is just wonderful...

You'll get your meds and you'll get cured! :)  Hang in there!!
Dx'ed HVC and cirrhosis Nov, 2018
GT: 1a; TN; F4-44
Started Epclusa and Ribavirin on Mar 2019

Offline Sage

  • Member
  • Posts: 15
Re: Insurance Denied
« Reply #14 on: May 30, 2019, 01:33:35 am »
 :D Approved! woot woot. Just have to wait for it to be delivered to my small town pharmacy. Not nervous yet. It will probably hit me like a brick later.
1a
F2
Viral load 3,260,000

Thyroid Cancer
Basal Cell Cancer
Breast Cancer

Offline lporterrn

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  • LucindaPorterRN
    • LucindaPorterRN
Re: Insurance Denied
« Reply #15 on: May 30, 2019, 01:03:25 pm »
Sometimes nervous and excited feel alike - may you heal quickly. Hope we are all celebrating your success soon.
Lucinda Porter, RN
1988 Contracted HCV
1997 Interferon nonresponder
2003 PEG + ribavirin responder-relapser
2013 Cured (Harvoni + ribavirin clinical trial)
http://blogs.hepmag.com/lucindakporter/

Offline LindaBalz

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    • FB
Re: Insurance Denied
« Reply #16 on: June 02, 2019, 08:56:52 am »
awesome that youre approved!

Linda
LB

Offline Sage

  • Member
  • Posts: 15
Re: Insurance Denied
« Reply #17 on: June 02, 2019, 02:22:18 pm »
Day 3 on mavyret and not a side effect in sight

HAPPY
1a
F2
Viral load 3,260,000

Thyroid Cancer
Basal Cell Cancer
Breast Cancer

Offline lporterrn

  • Global Moderator
  • Member
  • Posts: 1,976
  • LucindaPorterRN
    • LucindaPorterRN
Re: Insurance Denied
« Reply #18 on: June 03, 2019, 03:44:43 pm »
This tends to be what we hear - how wonderful to hear it from you too.
Lucinda Porter, RN
1988 Contracted HCV
1997 Interferon nonresponder
2003 PEG + ribavirin responder-relapser
2013 Cured (Harvoni + ribavirin clinical trial)
http://blogs.hepmag.com/lucindakporter/

 


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