Anyone know if Insurance will pay for these new drugs?

[GrammyA]

Very exciting news today with my visit to the Hep Dr. - he is going to try to get pre-approval from my insurance company to start me on the 2 new oral drugs (cannot recall the exact names) that you take 1 pill each per day for only 12 weeks with a 90% SVR and minimal side effects.  I have not achieved SVR in 2 prior attempts with the most recent being with triple TX and Incivik which ended last January….am 1b with cirrhosis and 61 years old.  He tells me the plan would cost about $100,000 for the 12 weeks of pills and he is not sure if the insurance companies will approve it.

Anyone else trying this and thinking your insurance might pay?  

[JimmyMose]

I think I know what happened. I saw this is post on the recent post/reply list. When I went to reply to the last post didn't look at the date of IrishFireandIce post.  Apparently a MedHelp mod removed the last post before my reply.  That is how some old post show up with the most recent reply still is old.

[JimmyMose]

Welcome new member.  Congratulations on getting the new meds approved and we all hope and pray that you will achieve SVR. Feel free to post any questions or comments about your treatment.

This was an old thread but I'm glad someone replied to bump it up.  I re-read it and remember it well.  And Yes GrammyA did achieve SVR. and hope she is still doing well.
http://www.medhelp.org/posts/Hepatitis-C/SOLVALDI-OLYSIO-WORKED--finally-something-worked/show/2214436#post_11197639

[IrishFireandIce]

I am new to this forum. I'm a 54 year old diabled woman. I have Medicare as Primary and full Medicaid as secondary and AARP United Healthcare for Part D.
I am Hep C positive and have a LOT of liver damage. I was approved for the S & O treatment within 2 days of my doctor submitting the info and am due to get my meds delivered first thing tomorrow by FedEx.
Just wanted to throw in whatever I can to help others.
Thanks for all of the great information on here.

[kokomojo]

Check out "Wheat Belly" also

[JimmyMose]

Depending on your income and family size you may be eligible for assistance with private insurance or Medicare Part D

Patient’s income must fall below 500% of the Federal Poverty Level.for household size

The Sovaldi Co-pay Coupon Program, which provides co-pay assistance for eligible patients with private insurance who need assistance paying for out-of-pocket medication costs. Most patients will pay no more than $5 per co-pay. - See more at: http://www.gilead.com/responsibility/us-patient-access/support%20path%20for%20sovaldi#sthash.AYZZRDoo.dpuf

Gilead will provide support to the Patient Access Network (PAN) Foundation, an independent non-profit organization that provides assistance for eligible federally-insured and privately-insured patients who need help covering out-of-pocket medication costs. -

I am pretty sure the "donut hole" is included.
https://www.panfoundation.org/hepatitis-c
Hepatitis C
Program Status
Open - We are accepting applications for new and renewal patients. If your application for assistance is approved you can begin receiving funding immediately.
Maximum Award Level

$7,000 per year
Eligibility Criteria

Patient should be insured and insurance must cover the medication for which patient seeks assistance.
The medication must treat the disease directly.
Patient must reside and receive treatment in the United States.
Patient’s income must fall below 500% of the Federal Poverty Level.

PAN Foundation can consider for payment any co-payment, deductible, or co-insurance amount for medications that are used to treat the disease for which you have been awarded assistance. Medications that treat the side effects of your diagnosis are not covered, and charges for office visits and administration are not typically covered.

[primaburgess]

Thanks Mark.  This medicare stuff is overwhelming and your answer help me understand my choices.  Good luck with your treatment.....

[NYCMark]

Hi.  I'm receiving my drugs under my employee health plan. But I will retire this year or next and will need to get Medicare Part D.  I was looking at the drug coverages under that plan; my understanding is that, whichever plan you choose, you still need to pay up to $4500 or so in drug costs until you reach their "catastrophic coverage" level, and then you pay "only" 5% of drug costs.  So there really is not a $6000 savings compared to your current plan coverage, it seems.  Someone please correct me if this is wrong.
(BTW, I am starting my 3rd month of Sofosbuvir + Sovaldi + ribavirin.  I seem to have been approved without too much difficulty before the insurance companies started rethinking approval of this combo.)

Mark

[somuchmore2]

I am looking at around 72% chance of SVR.

Geno 1a (non-responder even through clear through 48 weeks last time)
Treated 3x last with Pegasys/Incivek
IL28B T/T
Cirrhosis (but compensating well)
59 year old
HCV dates back likely to 1973

Oh!

Do you think I am about correct in my expectation?

Thanks,

[primaburgess]

I will shortly be on Medicare and have checked out United Healthcare Part D and they have approved Solvaldi and Olysio as Tier 5 drugs.  I called again a couple of days later to see if another employee would say the same thing and indeed they have approved each drug as stand alone drugs.  No word on Cosmos.  I currently have Aetna under an employee plan with a $6000 deductible. My doctor is currently applying for Cosmos coverage with Aetna which I have been told they will probably not approve it and then the doctor will appeal.  If I could be sure United HC Part D will pay I would much rather save my $6000 and cancel my Aetna coverage.  

Has anybody else on Medicare found a carrier that would approve Cosmos under their Part D coverage?

[can-do-man]

From desrts thread...

But some patient groups and health providers are beginning to question the cost of that benefit.

"The experts recommended the drugs should be used only for patients with severe hepatitis complications, such as liver cirrhosis."

http://www.medhelp.org/posts/Hepatitis-Social/low-value/show/2119797
------------------------------
Things might tighten up a bit for those that "just want it"

[JimmyMose]

Olysio is made by Janssen Therapeutics, Division of Janssen Products, LP  Johnson & Johnson

Sovaldi is made by Gilead who has stopped trials and involvement with Olysio.    
Gilead has ledipasvir and has applied for approval with Sovaldi

http://www.gilead.com/news/press-releases/2014/2/gilead-files-for-us-approval-of-ledipasvirsofosbuvir-fixeddose-combination-tablet-for-genotype-1-hepatitis-c

It's really hard to predict if a insurance company will cover Sovaldi and Olysio off label until your doctor submits a pre-approval application.which may be denied and have to be appealed. Without specific details of a patient's conditions, blood test, biopsy direct or indirect marker fibrosis level cirrhosis scores, previous treatment, platelet and etc it's hard to guess or offer suggestions.  

I assume that your boss has geno1 if so then Sovaldi and ribavirin are for 24 weeks for Inf ineligible. Or did Blue Shield just agreed to cover Sovaldi and ribavirin for 12 weeks with your boss paying for the Olysio?.

Sovaldi cost about $170,000 24 weeks  Sovaldi/Olysio combo for 12 weeks about $85,000 plus $70,000 or about $15,000 less  

Has he asked his doctor to proscribe Sovaldi/Olysio combo and request approval from the insurance company? If denied he can appeal.  

[taominatrix]

So...what insurance companies DO provide coverage for Olysio? Are ANY??? Blue Shield just agreed to cover Sovaldi and ribivirin. Which is better than nothing, but my boss' doctor really feels that the Sovaldi/Olysio combo would be the best treatment option for him. As he's not eligible for income based discounts, he's considering just paying out of pocket for the Olysio - but even for someone who's relatively well off financially - without the insurace covering at least part of it -  it's still a LOT of money. If Olysio is priced so high that insurance companies are universally refusing coverage - how does Gilead expect to bring in any profit off of it?

[JimmyMose]

I posted to this forum but it was moved to Hepatitis Social Community

Go to this link for more info and link to Formulary Lookup Tool to look up the new Hepatitis drugs to see if they have been added to Medicare-Plans or Non-Medicare-Plans in the USA


http://www.medhelp.org/posts/Hepatitis-Social/Formulary-Lookup-Tool---US-drug-status-for-health-plans/show/2091595

[giska]

Does anyone know aetna covers this new drug solvaldi with co.pination for 12 week regime . My husband is in process of blood test to k ow his IL28 type
Then may start if insurance covers.

[giska]

Does anyone know aetna covers this new drug solvaldi with co.pination for 12 week regime . My husband is in process of blood test to k ow his IL28 type
Then may start if insurance covers.

[NYCMark]

Yes thanks Will, the Cosmos results were the impetus to start this round of treatment -they figured the insurance companies would have to go along with such good results even though not specifically approved for use together.  With or without Riba, the results were excellent using Sof. + Smp.
I'll check back after lab tests are in next week.  

A question - has anyone here on Simeprevir suffered from an elevated bilirubin?  I know that is on the adverse effects list. I can imagine now that I have a slight yellow-ish cast (and I'm usually quite pale).
Mark

[willbb]

Hi mark.
.You doctor is most likely reducing the Riba because he would seem to be well versed in the research(linked below) that shows that  while doing the combination of these two drugs that RIBA is really on no consequence Actually in trials  patients with F3/F4  fibrosis levels did  4 % better without  it and would not want to jeapordize your therapy by  the onsetting anemia

Hope that explains possibly his rational........

Best of luck with your tx.

Will

http://www.clinicaloptions.com/Hepatitis/Treatment%20Updates/HCV%20Keeping%20Up/Interactive%20Virtual%20Presentation/IVP/Pages/Page%201.aspx

Slide 2 of sect.. 3  discusses use with and without  Riba

[jules2551]

2. It could be from the ribavirin/anemia beginning.  Yes, I would certainly reduce, and then stop, that drug if it turned out to be unmanageable.  I think my doc hoped to maximally increase my chances of SVR this time, since I have relapsed after the last 3 treatment attempts.

**************************

Why on earth would you recommend reducing Riba since you relapsed after 3tx?  I just dont understand

[milliehepc]

I went to the conference in NYC given by Dr. Ira M. Jacobson, medical director of the Center for the Study of Hepatitis C at the Weill Cornell Medical College, New York, who spoke at the annual meeting of the American Association for the Study of Liver Diseases.

He is not directly seeing me by one of the doctors there agreed to put me on the Sovalzi and Olysio.  I am treatment naive...stage 2/3 (don't know why my biopsy in 2011 got this - geno 1A.

Treatment Naive...now the question is how much?  They said, I could get it affordable but affordable.  I am going to my real Hep C doctor next week - at NYU to see if he also would agree.  But, with al the good information if he does not I am willing to go with WCMC because of the promising outcome.   I've been waiting for these drugs and here they are right?

Now - just need to know how much because I cannot afford very much co-pay...I have Oxford.  Will let you all know once I find out..... Good Luck to all of us.....

[NYCMark]

It sounds like you are doing just great!
I have minimal side effects: I do get fatigued in the afternoons, but
1. I always got tired in the afternoons (I still work 8-5 every day) and
2. It could be from the ribavirin/anemia beginning.  Yes, I would certainly reduce, and then stop, that drug if it turned out to be unmanageable.  I think my doc hoped to maximally increase my chances of SVR this time, since I have relapsed after the last 3 treatment attempts.  I'll discuss this in more detail and let you know his reasoning.
Let us know how you do with you blood test results.

Mark

[GrammyA]

Thanks so much for the kind thoughts - I will let you know how it goes every step of the way so YOU know what might happen while you are killing the dragon with me!

[Pamelajean1]

Grammy, great news! A 30 sec hot flash? After pms...I can handle that. :)
I think about you everyday....just think! You're free from the beast! You're on your way to be cured!
My script is at the pharmacy now waiting insurance approval...Aetna, so I hoping for the best!
Let us know about your labs....

[GrammyA]

Hey Mark,
It is interesting that my doctor (like many others) believes you can achieve SVR with just the Sovaldi and Olysio... No Riba.  So if you have issues that are difficult to deal with you could just stop the Riba and still succeed..... right?   Not sure but it sounds logical.  My 2nd week ends tomorrow then labs drawn on Friday morning.  I still feel really good so hoping the white cell count is staying strong.  Lets continue to monitor each other and compare notes.  So far all I have noticed is.... 20 minutes to 30 minutes after taking the pills I get a surge of hot flash all over that lasts maybe 30 seconds then it is gone.  I have had 2 headaches that within 20 minutes of taking an extra strength tylenol they totally disappear.  And, I had 1 wave of nausea after eating breakfast one morning but it lasted only about 10 minutes then POOF - gone!   SOOOO much better then last treatment attempt....... 10 weeks to go!

[NYCMark]

I'm so glad you're having an easy time of it this go-round.
As you remember, I too am on the two drugs you are taking, with the addition of ribavirin.  I finish 1st week tomorrow, and have been feeling mainly well (some afternoon fatigue hits me suddenly). Will go for blood tests after 14 days and then again at one month.  Will keep you posted!