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
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
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.
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
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 ***@****.
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