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315996 tn?1429054229

Insurance Coverage, the latest

A friend in a government HCV organization received this outline of the treatment practices of several insurance companies. It seems to fit right in with what my doctor was saying.

Based on your question related to navigating through insurance denial for HCV treatment access.

I looked up Harvoni, Solvaldi and Viekira Pak using the fingertip formulary lookup tool  http://www.fingertipformulary.com/home/ and checked on the coverage across three common insurance companies. The results are below by insurance company.

o Kaiser NW
Harvoni – not covered
Sovaldi – tier 2- This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
Viekira – not covered
o Providence
Harvoni – not covered
Sovaldi – Tier 2 - This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
Viekira – only covered through Healthshare (Medicaid - Providence Oregon Option with prior approval)
Providence PA form - https://healthplans.providence.org/~/media/Files/Providence%20HP/pdfs/pharmacy/Documents/priorauthorizationform.pdf
o Healthnet
Harvoni – tier 3 with prior approval needed. This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.(no PA form online)
Sovaldi  - tier 3 with prior approval needed. This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.(no PA form online)
Viekira – Tier 3 or Tier 4 depending on the Healthnet plan purchased. This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.


I also called the Gilead Patient Assistance Program (PAP) phone line and spoke with a representative because they cover Harvoni and Sovaldi. The Gilead PAP is called My Support Path (www.MySupportPath.com ). I did not call AbbieVie’s PAP – but I can if you need me to see what their patient assistance program (PAP) access process is – although it is probably similar.

Since I did not know specific information...I asked general questions.

The person at www.mysupportpath.com relayed that
• If a medication is on formulary - A physician needs to (1) apply for prior authorization and save the denial, then (2) appeal the denial and be denied again (3) once the second denial occurs, complete the intake form and submit with the two denials.
• If a medication is NOT on formularry – (and I specifically asked about Harvoni – since it is not covered on two of the plan.) The answer was that it was the same process and that the Gilead/MySupportPath PAP would need two denial letters with the intake form submission.

I wish the process was less time consuming but if the physician is willing to support submitting the authorization to be denied – and then appealing the denial - it looks possible to get access.  

Also, since the medication are listed as tier 3 and 4 for Providence and Healthnet-  they may be expensive out of pocket. Copay support is available from the companies and I have included the information about copay support below.

Gilead Sciences
Drugs covered: Harvoni (sofosbuvir + ledipasvir), Sovaldi (sofosbuvir)
Contact Information: 855-7MY-PATH (855-769-7284) or www.MySupportPath.com
Program Details: The Co-pay Coupon Program reduces co-pays to $5 in most cases for those who qualify. Financial aid for as much as $16,000 is also available to go toward prescription deductibles and coinsurance obligations. The program is open to those with a maximum household income of $100,000 for up to a family of three, and 500 percent of federal poverty level for families with four or more members

AbbVie Inc.
Drugs covered: Viekira Pak (ombitasvir + paritaprevir + ritonavir) + (dasabuvir), Moderiba (ribavirin)
Contact Information: For Viekira, 844-277-6233 or www.viekira.com/proceed-program. For Moderiba, 844-663-3742 or www.moderiba.com/patient-support/financial.
Program Details: For Viekira, contact company to determine eligibility and amount of coverage. For Moderiba, $5 out-of-pocket co-pay card may be printed from website (for those who are eligible).

Lastly - the Director of the Caring Ambassador’s Program Lorren Sandt has offered support to people who are having trouble accessing medications. If this turns out to be the case – I would recommend contacting her 503-632-9032  or ***@****.



How wonderful it is that nobody need wait a single moment before starting to improve the world.
~Anne Frank


5 Responses
Avatar universal
I find this so sad....both having the patients who do not feel well having to go through all of this and taking the doctor's time to send letters, fill out forms, etc. I can't imagine any other disease state where you have to wait until you are sicker to be treated or do all this prep work to maybe get the care you deserve. Ugh!

Lorren is a wonderful resource; so is Help4Hep at 1-877‑435‑7443.
Avatar universal
That's the way we roll. We all had to go through the process to get the meds. Your doc's team does the paperwork. The team should already know what Ins Companies covers what. They will not waste time winging it. Many of us were approved the first time. However it is a process that your doc takes care of beginning with labs, fibroscan etc. It's the doc that requests the script. And that's how it rolls. Sicker people have nothing to lose. Why not start with the most sick? Why use the healthier heppers as guinea pigs?
Soon, very soon as positive results of 'cures' come out more and more, anyone whom the doc writes the script for will likely be approved. If you don't trust your doc, find another.
6708370 tn?1471490210
Kaiser does have Harvoni in their formulary:

https://healthy.kaiserpermanente.org/static/health/pdfs/formulary/cal/2015_ca_marketplace_formulary.pdf

For North West as of 2/20/2014
Avatar universal
"Why not start with the most sick? Why use the healthier heppers as guinea pigs? "

I think that part of the reason behind using the healthiest patients in the trials is that the drug companies get the best results from healthy patients.

As far as getting the sickest treatment first....one can a case for that. But it is because of the outrageous price of the drugs that there is not universal coverage for everyone. With hep C, there are people who really feel like crap who don't have late stage disease. I hate that they don't have access. I find it sad to think about the patients who don't feel well, yet know there is a drug that would cure them in 8-12 short weeks, but they can't have it. So, from a purely humanitarian point of view, I HATE the barriers to access. And, the less people who are walking around with  HCV, the less people will be at risk of becoming infected.   I am thankful for the advocates and those on the Fair Pricing Coalition that they are fighting for access for everyone.
317787 tn?1473358451
Hey there, thanks so much for getting this information and placing it here for everyone.  Really nice of you
Dee
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