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Harvoni Help: Getting Coverage

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Response to Molly Thomas: https://www.youtube.com/watch?v=HBhNs...
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maybe you can help me...please... T work with the federal govt and i have high option for self and family. I spoke with the benefits rep with the federal govt and he stated that it's the health provider I have to go through. I noticed that you mention that it's mandatory by law that the health provider has to cover me, but the health provider is stating that I am not covered even though they have copies of tests and a letter from my doctor stating I do need harvoni and only harvoni will work for me. What can I say or do to convince my health provider that they must cover my medication ? Do you have a document (law in the books) that I can show my health provider. Should I convince my doctor to go the pharmaceutical route ?. He is stating that I should go with medical tourism and it would cost 3k but I would have to fly to the Philippines and get seen at St Luke. I know 3k is better than 100k. Can I contact the Pharmaceutical companies myself or must I go through my doctor? Thanks
ONEEZE (9 months ago)
Hey sorry it took so long to get back, I got locked out of my account. This is my old channel. I should be able to help you, here is what I will need: Demographic information (Name, DOB, Address) Insurance ID Doctor's Name and address Send that information to my secure fax (888) 286-3058. It looks like EnvisionRx is the pharmacy benefits manager for the plan. I have not done any work in Guam before, but the rules should be the same as for other US territories, such as Puerto Rico, which I do know fairly well.
I live in the island of Guam and my insurance company is Take Care. Thank You for your quick reply
Sons of Apollo (9 months ago)
What state are you in and which insurance company do you have?
serferten (1 year ago)
Yes, you lay it out but fail to point out the heartless role Gilead has played in pricing this drug at backbreaking prices. Do they have a right to do it, sure? Do I have a right to point out how cruel they are, sure, too.
mike duda (2 years ago)
harvoni costs $1160 per pill & u need 90 pills , do the math
mike duda (2 years ago)
f-1 or f-0 , u wont b approved
mike duda (2 years ago)
if your fibroscan isnt atleast an f-2 , u wont b approved for any hep c treatment period , thats the minimum requirment for harvoni treatment ,f-2 fibroscan
Jeremy L (1 year ago)
mike duda my dr friend in Canada just told me the other day that he has not even heard of it and he’s got 13 clinics in Vancouver. Im meaning he’s a smart dude and that would make more sense after reading your reoly
Sons of Apollo (2 years ago)
I can't say for Canada. I live in the United States, the rules are different. I have no idea what the qualifications would be there.
mike duda (2 years ago)
+Sons of Apollo it dont work that way for harvoni in canada , even if u got 10 other deadly diseases & death is possible without treatment , u aint gettin harvoni under f-2 , even if u got liver cancer , if your fibroscans under f-2 , the hep c specialist tells u to not even waste your time apply ing
Sons of Apollo (2 years ago)
If you can make a strong enough case nothing is in stone. I've approved many below an F2 while I was the one reviewing claims when I worked at a PBM and also now on the other side at a hospital. If you look at your denial letter you will see that one way to get it approved is to meet the milan criteria. In some cases, one which I had last year, there can be liver cancer before major fibrosis has taken place, usually as a result of the patient having some other condition in conjunction with Hep C. A fibrosis scan is not required in that case. If someone is an otherwise health person besides the fact they have Hep C then you would be right, but many people have comorbidities that can be worsened by the presence of Hep C which makes its immediate treatment a medical necessity. Two weeks ago we had someone die while they were on treatment, they were F3. Even though they were an F3 the complications due to the other disease states exacerbated the problems and they died as a result. These are situations where immediate treatment is a medical necessity and if you have someone like myself who has insider experience and very broad medical knowledge you can get people approved before having to wait for an F2 metavir score. Hope that clarifies it.
Catholic Seymour (2 years ago)
Hello, I have hep c genome type 3. I have insurance with Scott and White. I have been declined on the original claim. I have just been declined on the appeal process. The insurance company tells me that I have to now file an expedited appeal. There is no guarantee that I will be approved. The rep told me that it looked like I had to follow the appeal process all the way to the top. It is like the insurance company is trying to run out the clock. I am not eligible for medicare or medicaid at this point even though I am 100 % disabled and live on Social Security. My doctors and I have given them everything that they have asked for to no avail. I don't feel that I have a whole lot of time left. I was told in 2013 that I only had a year to live but if I took care of myself I could live as long as five years. Any direction you could give me would be greatly appreciated. Thank you so much.
Catholic Seymour (2 years ago)
+Sons of Apollo Thanks for your help. They gave me no specific reasons in the denial other than what I have related to you. I have never been treated for this disease. I have been OK until the last couple of years. The pharmacist told me that S&W had found some loop hole to delay approval. She said that I could take this to the Texas board of insurance and win. I think that they are just stalling. Seams like the death boards are a reality of Obama care. Don. I just read the recommended treatment for my case and what my doctors prescribed is on par with the recommendations. It has an 86% cure rate. where as the older method has only a 58% cure rate. I think that S&W wants to pay for the older interferon type treatments. I don't think I would make it through that.
Sons of Apollo (2 years ago)
I called them today, but I could only gain so much information since I am not your provider. From what I can gather I suspect they are declining the regimen you have in favor of a different one. What exactly did the letter say? There should a detailed reason as to why it is inappropriate. It seems like they would approve with what you have, but again I don't know all your details, something like 24 weeks of Sovaldi/Ribavirin or 12 weeks Sovaldi/RIbavirin + weekly interferon. It seems they will approve Daklinza for someone who is F3, but not F4. Can you get around that? Probably but that would require your entire history, anything you have taken for it in the past, other medications, and I would have to write it up and submit that personally, which I won't be able to do since I don't work with your doctor's office. From a practical perspective it may be best to call them on Monday and ask them well what DO you approve for genotype 3 for someone with cirrhosis? That may be the best way to go especially since time is of the essence for you. They may be able to get that appeal overturned, they may not, either way it will take a while and I cannot speak for the probability of it being overturned since I don't know what exactly they said. There may be other reasons they denied it. Here is the PA criteria according to their site and you will see exclusion criteria. Just hit crtl+f and search Daklinza https://legacy.swhp.org/sites/default/files/SWHPCommercialandSelfInsuredDrugScreeningCriteriaGuidance.pdf See what they will approve and talk to your doctor about it. Here are the guidelines for people who have never received treatment. The results are fairly close. If you have had previous treatment I can get you those as well. http://www.hcvguidelines.org/full-report/initial-treatment-hcv-infection I know its a lot of information, but without the exact reason as to why they denied it, it makes it harder for me to give more pointed advice because it could be many different things. Again maybe the best thing would be to ask what the insurance company wants to do for your situation and then work form there since you may be short of time. Let me know if you have any other questions.
Catholic Seymour (2 years ago)
+Sons of Apollo Scott and White is my insurance I purchased through the Market Place plans. I live in Texas. The Drugs that I applied for are solsovar and daklinza for genome type 3. I have known about the hep c since I was 38 and I am now 60.
Sons of Apollo (2 years ago)
+Catholic Seymour Okay let me ask you another couple questions. What drug did you apply for, was it Harvoni or something else? What state are you in and when you say insurance through Scott and White, is that the insurance company or is that where you work? If it is not the insurance company then what company handles your prescription drug benefits?
Catholic Seymour (2 years ago)
+Sons of Apollo I think it was F4 and F3 at best. The reason that they gave me was that the treatment was not medically necessary or inappropriate. I talked with a rep today and explained that I had been diagnosed with end stage liver disease in 2013 an given only a year to live at that time. However I was also told that if I got my act together it could be four to five years before I needed a liver. I am Roman Catholic and I have a problem with accepting a liver that comes from someone who has just been declared brain dead rather than someone who actually died at the time of harvest. As you can see my only hope is getting the drugs that I need to live. Anyway I was told by the rep that I was going to have to appeal the case all the way to the top. It seams like the game is to run the clock out... sad but that it the way it appears from my perspective. I called back latter in a bit of a huff and spoke to another rep and explained that the reason for denial was just not good enough.  want them to tell me why it is not medically necessary when two different doctors say it is. I am supposed to call back Monday and speak with the powers that be in a conference call. I honestly don't think I have a year left. I feel this disease drain me a little day by day and week by week. I am sick 5 days a week and spend most of my time in bed. I can't hardly take care of myself anymore. If they deny the final expedited claim I think I have to wait another 180 days before I can file again. Sorry for my complaining and I really don't mind dying when my time comes. However I feel that I have a responsibility to live out my days and finish the reason I was born in the first place. Thank You for your time and understanding. Don
Elizabeth C (2 years ago)
Excellent presentation, learned alot
Sons of Apollo (2 years ago)
+Elizabeth C Thanks you! If there are any additional questions I can answer, please do not hesitate to ask.

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