Time Frame for tx Approval

[iwillbeatthis]

I just called my Dr. and I just asked them if they knew if the shots would be covered thru my insurance, and the gal I was put thru to was telling me that they had to be covered because you must take the shots and pills together.
I told her I knew that, but did that automatically mean that the shots were covered? and she basically repeated herself. She also started in on the approval part, that there was much paper work to do regarding approval and psychiatric evaluation in this situation with this medication, and with the specialty pharmacy to get the shots, she then asked if I had had a biopsy yet, I had to remind her that I gave all that to the doctor....
Question 1 is is a 3 year old biopsy going to satisfy them?
and 2, about how long has everyone experienced this 'approval period' is in getting the paper work together for insurance from the doctor, and 3, what of this psychiatric evaluation, does everyone have to go thru it? My doctor didn't give me all this grief when I was there to see him, he said I was healthy and cheery and perfect to get going soon. Thanks for any help, Bree

[iwillbeatthis]

Thanks, I am not a sit by and do nothing person, I like to know what is happening, what I can do, although I didn't want to step on the docs toes, he has only given me reason to believe he is really on top of things. I have scopes on Wed with him, then a follow up on Aug 23rd, which I am assuming will be when the insurance details will have been taken care of ?
Yea, the gal did mention the class, the biopsy, the psychiatric evaluation, it did sound like she was reading from a manual, which is ok, I am willing ready and able so I think this will be ready by month's end, which is the earliest I was even planning on starting.
Thank you all.

[Bill1954]

Hi Bree,

I’m glad you’re getting this out of the way now; it can be a bit of a process as you’re finding out. This is why I’ve been subtly nudging you in this direction :o).

It might be nothing of consequence to you at all. The ‘psych evaluation’ might only be the doctor’s blessing; it doesn’t have to be a formal thing, to my knowledge. If he thought you’d be a good candidate for therapy, then that might have been enough. Sometimes, if a patient has been hospitalized in the past, or is otherwise outwardly mentally ill, the doctor will require psychiatric care or evaluation from a shrink before approving the treatment drugs. They have a propensity to exacerbate depression in some individuals, and also cause some folks with substance abuse issues to relapse, hence the consideration to psych eval.

Yes, it might involve a week or more for prior authorization; that was my experience anyway; your policy might not require this; you won’t know until you ask or the time comes to order the drugs.

You will most likely attend a class to show you how to use the drugs; this typically amounts to a half day seminar sponsored by the pharma company. They will likely discuss the importance of compliance, explain how to reach the 24/7 nurse’s hot line, and go over the mechanics of self-injection.

None of this is a particularly big deal but it’s generally more involved than picking up an order of antibiotics at the local pharmacy.

Most insurance companies contract with specialty pharmacies in order to get the most favorable prices on the HCV drugs; we usually get them shipped via Fed-Ex or UPS and they come in refrigerated cold pack boxes shipped overnight express.  

You might allow two or tree weeks for the entire process, including class, insurance authorization, etc.  Then again it might move faster than that, but don’t count on it.

Good luck—

--Bill

[FlGuy]

The approval process can take a couple of weeks to get finalized.  With the expected cost to the insurance company, you can expect that a 'medical director' at the insurnace company need to give a thumbs up.

Assuming you go for treatment and it's covered by your insurance, you need to know if there are milestones in treatment progress that need to be reported by your doc to insurance.  Insurance my require proof of progress to continue authorizing rx refills.  Whatever the rules are, make sure you play by them to include understanding what your doc role is.

[spectda]

If you dr is experienced with treating hep c they will get this approved for you. Before I went into a trial my doc said he would get the approval and to let them take care of it. Many insurance companies have their own pharmacy that they want you to get the medication from so they get the best deal for themselves and often for you.
Good luck-dave

[can-do-man]

Answer to number1. A 3 year bx should be just fine. For number 2 thats a good one, it seems to vary with everyone, its always seems to be hurry up and then wait. As for the thrid one never even had a psychiatric exam brought up. Sounds like your doctor is on top of this and your nurse is just going by some script.......... Wouldn't worry about it, good luck to you.

cando