What to Do When you are Denied Approval of Medication for Hep C by your Insurance Company

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getcured
Regular Member


Date Joined Jan 2015
Total Posts : 64
   Posted 1/31/2015 10:46 PM (GMT -6)   
Hi All- I am currently on week 4 of treatment for Genotype 2 and have been finding this site very helpful, especially regarding side effects and what is "normal" on treatment. Thank you so much for all of your informative and supportive suggestions and comments.
I had a lot of difficulty getting my insurance company to cover the cost of the medication (Solvaldi and Ribarivin) and had to appeal 3 times, the last time to the State where I finally was successful. Because I have noticed more comments posted recently regarding insurance issues and, in the event that it may be helpful, I have posted below an outline that I compiled following my appeals. Please post if you have additions, suggested changes, questions etc.

What to do When you are Denied Approval of Medication for Hep C by your Health Insurance Company

If your insurance company denies you approval for medication for Hep C you will want to consider pursuing one or all of the following actions detailed below: seek financial assistance through the pharmaceutical company that manufacturers the drug/s your doctor has prescribed; appeal the decision of your insurance company to deny you medication; seek the assistance of a Patient Advocacy Program to help you through this process.

A- Seek Assistance from the Pharmaceutical Company that Manufactures the Medication that you have been Prescribed-
Find out who manufactures the medication that you have been prescribed and apply for any patient programs the company offers that will cover or help cover the cost for that medication. The programs fall into two types: Co-Pay Programs and Patient Assistance Programs. While the medications are changing rapidly, listed below are the programs and contact information for the medications currently prescribed for Hep. C:

1-Co-Pay Programs- These programs offer people with private insurance help with the co-payments or coinsurance costs required to obtain Hep C medications. Many of these programs are not available to those enrolled in Medicare, Medicaid, or other government-based prescription plans.
AbbVie Inc.
Drugs: Viekira Pak (ombitasvir + paritaprevir + ritonavir) + (dasabuvir), Moderiba (ribavirin)
Contact: For Viekira, 844-277-6233 or www.viekira.com/proceed-program. For Moderiba, 844-663-3742 or www.moderiba.com/patient-support/financial

Genentech/Roche
Drugs: Pegasys and Copegus
Contact: 888-202-9939 or www.activatethecard.com/pegasys/welcome.html

Gilead Sciences
Drugs: Harvoni (sofosbuvir + ledipasvir), Sovaldi (sofosbuvir)
Contact: 855-7MY-PATH (855-769-7284) or www.MySupportPath.com

Kadmon Pharmaceuticals
Drugs: Ribasphere (ribavirin)
Contact: 800-364-4767 or www.hcvadvocate.org/community/community_pdf/Riba_CoPay_Cards.pdf

Janssen/Johnson & Johnson
Drugs: Olysio (simeprevir)
Contact: 855-5-OLYSIO (855-565-9746) or www.olysio.com

Merck & Co.
Pegintron and Victrelis
Contact: 866-939-4372 or www.victrelis.com and www.pegintron.com

2- PAP Programs
These programs offer free Hep C drugs to low-income people with who are uninsured or underinsured and who do not qualify for insurance programs such as Medicaid or Medicare.

AbbVie Inc.
Drugs: Viekira Pak (ombitasvir + paritaprevir + ritonavir) + (dasabuvir), Moderiba (ribavirin)
Contact: For Viekira, 844-277-6233 or www.viekira.com/proceed-program. For Moderiba, 844-663-3742 or www.moderiba.com/patient-support/financial

Genentech/Roche
Contact: 888-941-3331 or www.pegasysaccesssolutions.com

Gilead Sciences
Drugs: Harvoni (sofosbuvir + ledipasvir), Sovaldi (sofosbuvir)
Contact: 855-7MY-PATH (855-769-7284) or www.MySupportPath.com

Janssen/Johnson & Johnson
Drugs: Olysio (simeprevir), Procrit
Contact: Olysio 855-5-OLYSIO (855-565-9747) or www.olysio.com/hcp/experience; Procrit 800-652-6227 or www.jjpaf.org

Merck & Co.
Drugs: Pegintron and Victrelis
Contact: 866-363-6379 or www.merckhelps.com

B- Appeal the Decision *

1- Read the document you receive from your insurance company notifying you that approval for medication has been denied and informing you of the opportunities for appeal- Pay careful attention to the time in which you have to file an appeal, where and how (fax, mail, etc) the appeal must be sent, and what information must be included. You may be able to proceed with an appeal to your insurance company and to an independent entity (usually this is an appeal sent to a State office that, in turn, contracts with a group of private doctors to render a decision). Keep in mind that if the insurance company approves particular medications for Hep C but they are not the medications your doctor prescribed, you still have a right to appeal. **

2- Research your insurance company’s policy regarding authorization of medication for your condition- Seek out all information about your insurance company’s coverage for the medication for which you seek approval. Information may be found online or in the written information provided to you from the insurance company. To be certain you have the most up to date information about your policy you can call or write your insurance company and ask for that information. Read carefully through the company’s coverage policy to determine if the medication is covered under your policy (the “formulary”) and, if not, whether there are any exceptions for which you may qualify. Pay attention to what type of documentation (e.g. test results (fibroscan, biopsy), chart notes, etc) you will need to demonstrate that you meet the criteria for getting approval for the medication. Remember that your doctor’s office is dealing with many different insurance agencies and will not always know what is necessary to gain approval from your insurance company under your plan.

3- Keep a calendar with dates when appeals are due to be filed and decisions are due to be made by the entities to which you have sought appeal. Keep a notebook of conversations you have and include the name of everyone you speak to, the agency for whom they work, the date and details of the conversation.

4- If your condition does not fall clearly into the requirements for approval of Hep C medication (e.g. not in stages 3 or 4) collect information/research relating to your condition using data and information provided by your doctor, the library or the Internet- Highlight the information or research most supportive of your claim to obtain medication or treatment. For example, you may want to include research that demonstrates that failure to be treated is likely to aggravate another condition from which you suffer or that your condition is likely to deteriorate at a rapid pace without treatment. A lot of helpful, up to date and well respected research can be found on the American Association for the Study of Liver Disease (AASLD) website. http://www.aasld.org/

5- Request medical records from your doctors- Request records from all doctors that may have information supportive to your claim. You will have to fill out a medical authorization form and return it to the office before they will be able to give you the files. If the office will charge a fee to send records to you (versus sending them to another doctor for which there is generally no charge) you may consider asking to make an appointment for the purpose of reading the records and taking notes (sometimes the office will just sent you the record free of charge because they simply do not have the time or space to have you actually sit in the office and read the records!) Remember that if you have a specialist, he/she will not likely have access to your general practitioner’s/ internist’s records or records from other doctors that may contain information about your condition and that would be supportive of your claim e.g. psychologist, other specialists, etc. Even if your doctor does have access to records of other doctors, they will not usually have the time to go through them as carefully as you would.

Read through records for all relevant information (e.g. case notes of complaints regarding the medical issue for which you are requesting medication, notes describing the ailment, need for treatment, possible outcomes if treatment is not given, etc.) Take notes and/or mark the records with post-its.

Due to the extremely high cost of Hep C medications, many of the insurance company’s are restricting approval of medication to those patients that are in stages 3 and 4 or suffer from specific physical ailments that are caused by Hep C. These restrictions are the result of a Report from the American Association for the Study of Liver Disease (AASLD) last year that categorized the different stages of the disease into “priorities for treatment.” The insurance companies then used these categories as a justification to only provide medication to the highest levels of the disease. In October 2014, however, the AASLD clarified its recommendations and made clear that “their criteria was not intended to be wrongfully used by insurance companies to deny treatment to people for whom it is medically necessary to receive treatment.” This language should be included in any appeal from the denial of an insurance company to approve medication for Hep C medication based upon the argument that the patient has not yet reached stage 3 or 4 of the disease.

6- Write draft letters for you doctor- Doctors do not usually have time to weed through medical records, pull research together and write a comprehensive letter to an insurance company. Records from other doctors may be necessary to include in an appeal letter. Although you may be able to have one doctor send records to another, it is unlikely that he/she will be able or willing to pull out pertinent portions of the records. Consequently, it is very helpful, if not necessary, for a patient to pull portions of medical records together for your doctor to consider. When you submit the points of interest/letter or documents to the doctor, explain that you put the information together as a convenience to them and that they are certainly entitled to change it in any way they see fit. Even having your name, date of birth, insurance number and the address where the letter will need to be sent will be very helpful. Ask friends and/or family to help, if needed. A fresh perspective can help and take some of the intensity out of the experience of advocating for oneself while suffering with an illness. And remember that your letter needs to provide information but does not need to be a masterpiece!

7- Consider submitting your own letter- The insurance company and any person or entity considering an appeal from an insurance company denial of medication will focus primarily on the “medical necessity” documented by the doctor and the medical records. If there are things that will not be included in those documents, consider writing your own letter in support of the appeal. You may include information such as the way in which your condition has affected you physically or emotionally. You may also include justified reliance on insurance companies or doctors that led to an expectation of coverage or a worsening of condition, etc.

8- Keep copies of all the letters and documents that you file with your appeal

9- Keep going thorough the appeal process- The insurance companies know that most people will not proceed with an appeal and, if they do, that they will likely give up if they lose at the first level. Continue to proceed with the appeal to the extent possible. Once the appeal leaves the insurance company and goes to an independent third party, your chances of winning will increase. In the health insurance world the “squeaky wheel gets the grease” is particularly applicable.

C- Consult Patient Advocacy Programs
In addition to pharmaceutical patient assistance and co-pay programs, patient advocacy programs may help you pay for medication and navigate other issues relating to access to care, including insurance related issues.
Patient Advocate Foundation's Hepatitis C CareLine – The Patient Advocate Foundation PAF is a national organization providing professional care and management services to patients with healthcare access problems. The newly created CareLine will help patients across the country solve problems in all aspects of the healthcare system, including managing insurance. Through the Hepatitis C CareLine patients can get “benefit coordination, educational and financial resources, help accessing the latest available treatment, navigation through the appeals and reimbursement processes, as well as other patient services. Contact Information: 800-532-5274 or www.hepatitisc.pafcareline.org
Partnership for Prescription Assistance (PPA)- The Partnership for Prescription Assistance helps patients without prescription drug coverage get the medicines they need by matching them with the right assistance programs Contact Information: 888-477-2669 or www.pparx.org
Patient Access Network Foundation (PAN)- The Patient Access Network Foundation offers help to people with chronic or life-threatening illnesses for whom cost limits access to medical treatments. Contact Information: 866-316-PANF (866-316-7263) or www.panfoundation.org
The Bonnie Morgan Foundation for HCV: The Bonnie Morgan Foundation provides information about hepatitis C treatment and co-pay assistance programs. They disburse charitable donations for those who need help paying prescription drug co-pays and deductibles. Contact Information: 877-359-7235 or www.notwithoutafight.org

*The following websites were relied upon in compiling this document:
http://www.aasld.org/

www.pparx.org
www.hepatitisc.pafcareline.org
http://www.healingwell.com/community/default.aspx?f=25
http://www.hepmag.com/articles/hepatitis_paps_copays_20506.shtml
http://fairpricingcoalition.org/
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* Certain health insurance companies have begun only approving drugs made by certain pharmaceutical companies. In some cases, however, a drug made by a particular company may be the only drug that will be effective for your Genotype. For example, only Sovaldi, manufactured by Gilead Sciences,and Ribavirin are now prescribed to treat Genotype 2 patients. If your insurance company has decided to cover drugs exclusively made by Abbvie, for example, and denies you Sovaldi you may appeal to force your insurance company to cover Sovaldi for your treatment. This will change as more treatment options become available.
** If you are being denied a medication that is a “specialty medication” consider finding a specialty pharmacy in your area to help you. They generally get paid by obtaining medicine for a client and are skilled at helping people work through insurance issues and filing appeals. You may consider speaking to a few such pharmacies and making sure they are familiar with your particular medical issue and that you are comfortable working with them. Be careful, however, if the medication is being ordered through your insurance (rather then through a patient assistance plan) that you order your medication through a pharmacy that is approved by your insurance plan.


Post Edited (getcured) : 2/2/2015 7:13:22 PM (GMT-7)


**David**
Veteran Member


Date Joined Nov 2009
Total Posts : 3708
   Posted 2/1/2015 8:48 AM (GMT -6)   
I was turned down at every juncture, from interferon/ribavirin treatment, xifaxin and a transplant. BC/BS always denied, saying they were experimental. I wrote them and my doctors did as well. It worked each time.

Thank you for your extensive post on one's rights. Too many people give up, once they are turned down.

I was lucky, as BC/BS didn't fight as hard as many insurers do. People need to never quit fighting for their life.
nullum beneficium impunitum...

themiz
Forum Moderator


Date Joined Feb 2013
Total Posts : 1891
   Posted 2/1/2015 9:04 AM (GMT -6)   
Thank you for the great outline! We appreciate your positive approach to a negative experience. Big Hugs
themiz-Forum Moderator-Hepatitis
Wife of themister, a fine man living with ESLD. Transplant list-2013

“Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.” Kahlil Gibran

DMC2011
Veteran Member


Date Joined Jul 2011
Total Posts : 2504
   Posted 2/1/2015 9:34 AM (GMT -6)   
This is a wonderful resource!!!!! Thank you.
Left sided dx. 2011
Current med: Apriso 4 a day
Low dose BP med
Migraine med as nec
budesonide 9mgs
Cortenema as nec
Canasa 1 as nec
Vsl 3 packet Every couple days



Supplements: Looking into supplements now, changing plan
Diet: no lactose, low fat, no uncooked veggies, No honey or HFCS!! gluten free, no carageenan!!!

themiz
Forum Moderator


Date Joined Feb 2013
Total Posts : 1891
   Posted 3/14/2015 7:55 PM (GMT -6)   
I am bumping this thread today.

Buddy Blank posted a story earlier today about a Navy Vet denied treatment. That post reminded me of this good resource put together by our forum member, getcured. I hope everyone can get treatment, and the health care they deserve and will not give up hope. Big Hugs
themiz-Forum Moderator-Hepatitis
Wife of themister, a fine man living with ESLD. Transplant list-2013

“Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.” Kahlil Gibran

themiz
Forum Moderator


Date Joined Feb 2013
Total Posts : 1891
   Posted 7/25/2015 1:23 PM (GMT -6)   
Bumping for emwell :)
themiz-Forum Moderator-Hepatitis
Wife of themister, a fine man living with ESLD. Transplant list-2013

“Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.” Kahlil Gibran

emwell2
Regular Member


Date Joined Sep 2014
Total Posts : 33
   Posted 7/25/2015 2:12 PM (GMT -6)   
Thank you for the bump.
Maybe others will find this information as valuable as I do.
I believe that the more information I have in advance, the better off I will be.
LifeAsSeenByMe

themiz
Forum Moderator


Date Joined Feb 2013
Total Posts : 1891
   Posted 8/30/2015 4:31 PM (GMT -6)   
bump for all who need it! Big Hugs
themiz-Forum Moderator-Hepatitis
Wife of themister, a fine man living with ESLD. Transplant list-2013

“Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.” Kahlil Gibran

themiz
Forum Moderator


Date Joined Feb 2013
Total Posts : 1891
   Posted 1/16/2016 10:09 AM (GMT -6)   
bumping for new members.
themiz-Forum Moderator-Hepatitis
Wife of themister, a fine man living with ESLD. Transplant list-2013

“Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.” Kahlil Gibran

Barrylink
Regular Member


Date Joined Mar 2015
Total Posts : 124
   Posted 1/20/2016 9:17 AM (GMT -6)   
excellent resource material !! thank you.I'm thinking there are alot of people out there who need to know this,,
I will follow the upward road today; I will keep my face to the light. I will think high thoughts as I go my way; I will do what I know is right. I will look for the flowers by the side of the road; I will laugh and love and be strong. I will try to lighten another’s load this day as I fare along.

themiz
Forum Moderator


Date Joined Feb 2013
Total Posts : 1891
   Posted 2/15/2016 4:34 PM (GMT -6)   
bumping for new members seeking treatment.
themiz-Forum Moderator-Hepatitis
Wife of themister, a fine man living with ESLD. Transplant list-2013

“Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.” Kahlil Gibran

tblount
Regular Member


Date Joined Oct 2015
Total Posts : 82
   Posted 2/18/2016 7:15 PM (GMT -6)   
I've read that getting a doctor to inform your insurance company that you have mental issues has gotten rapid results. I know I was going crazy and having a panic attack when my Doctor could not fill a RX for Ribavirin... even after I found it and paid it took another week. I had a panic attack after waiting 28 days and making 58 telephone calls to my doctor's office.
M 64, detected after taking a 10 panel STD blood test
Started 12 week treatment with Solvaldi and Ribavirin 9-28-15
Genotype 2b -- Load Count 17,000,000
NOT DETECTED 12-22-15
Thank You Gilead

themiz
Forum Moderator


Date Joined Feb 2013
Total Posts : 1891
   Posted 3/23/2016 11:54 AM (GMT -6)   
bump for newcomers:)
themiz-Forum Moderator-Hepatitis
Wife of themister, a fine man living with ESLD. Transplant list-2013

“Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.” Kahlil Gibran

katmichelle
New Member


Date Joined Mar 2017
Total Posts : 3
   Posted 3/15/2017 10:03 PM (GMT -6)   
I just found this forum - we are having problems (actually it's our problem - insurance Medicare won't approve xifaxan 550) and we currently order from Canada.
We make too much money to qualify for Salix to approve us.

1800 per month is ridiculous and lactulose is not enough to keep my hubby's HE at bay.

Would you think a letter work as part of the appeal process?

Hubby's GI doc is saying he *may* not be writing the script for the Canadian pharmacy any longer.
Hubby has one fill left and just received a fill - so we have approximately 3 months supply left.

Thoughts on this?

Thank you for this information!

PS - the Medicare Part D is Silver scripts - any information on them?

katmichelle
New Member


Date Joined Mar 2017
Total Posts : 3
   Posted 3/15/2017 10:04 PM (GMT -6)   
PSS - hubby was approved first pass for Harvoni - but at that time he was still on ACA plan through the exchanges.

Price was 98K and our price was zero - so there are good stories out there.
I think BC/BS thought it was cheaper to cure him of HepC versus a transplant.

getcured
Regular Member


Date Joined Jan 2015
Total Posts : 64
   Posted 3/23/2017 11:00 PM (GMT -6)   
Welcome! Did your husband finish treatment on Harvoni while on his ACA exchange plan?

With respect to the drug, I assume that your husband's silver script plan covers the drug but that because it is in such a high tier it is too expensive. You husband can appeal the price that the insurance is charging for the drug by claiming that it should not be placed in such a high tier. You would want your doctor to write a letter of medical necessity explaining your husband's dire need for the drug and your husband can write his own letter explaining that he would not fit the requirements of the pharmaceutical assistance plan but that $550.00 a month is not possible given your income. As described in the outline, keep appealing until you get to an independent entity.
Regarding Canada, why does your doctor need to give you a certain type of prescription? If your doctor gives you a prescription are you not able to send it to a Canadian drug company without his having to get involved further?
Finally, you can use the following website to find out which medicare plans in your area include xifaxan on their formulary (the list of drugs covered) and which tier the drug is in. Depending on when your husband enrolled into medicare and other factors, he may be able to switch plans under a special enrollment period. If he is not entitled to a special enrollment period he may have to wait until open enrollment. Before switching, he would want to make sure that his doctors and hospitals accept the new plan, etc.
Hope this helps! Keep fighting and know we are with you.

MamaLama
Forum Moderator


Date Joined Oct 2010
Total Posts : 4786
   Posted 3/26/2017 10:25 PM (GMT -6)   
Hi, when Mike got his transplant in 2010, he still had Hep C. It was before the new meds were through their FDA approval.

His hepatic encephalopathy was AWFUL, worse. AAWWFFUULL. He needed the Xifaxan. At one point he was in the hospital and they started him on it as part of the hospital meds...no conversation about coverage. And in a couple of days, he was almost normal. He needed this medicine a lot.

His insurance denied a couple of times. I wrote a sob letter...asking if the soldier in the field were denied morphine simply because they would die of their wounds. Well, my man was a dead man if a liver did not appear mysteriously in the next weeks. 'And he needed the meds to either keep him stable until TP, or he would die and thus not need the meds for long. This and the docs letter did the trick. I was told to make the case that the patient had a terminal illness.

Just a thought.

Hugs,

MamaLama
MamaLama, Forum moderator - Hepatitis
Partner received liver transplant (May 1, 2011) FL
Hep C 1a Treatment - Sovaldi/Olysio (March - May 2014)
Undetected since week 4. Undetected 12 weeks post treatment.
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