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Anyone know if Insurance will pay for these new drugs?
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Anyone know if Insurance will pay for these new drugs?

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?  
Tags: drugs, new drugs, Oral, hep c, Gilead, insurance, newest treatment
64 Comments Post a Comment
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Avatar_m_tn
If I am reading this correct he is hoping to be able to go off-label and treat with both Simeprevir and Sofosbuvir together? It is worth a shot as the results of both of these together have had great results across the line.......... Good luck

http://hepatitiscnewdrugresearch.com/sofosbuvirgs7977simeprevirtmc435.html
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That would be great getting treated off label, if that's your case. What geno type are you?
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I see you're a 1b, missed that the fist time. It will be interesting to hear what the names of the 2 meds are next time you have a chance to ask.
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There are many different health insurance plans. The only way to know if your own health insurance plan with cover the treatment drugs and what your co-pay will be is the call them and ask where they are in the process of approving coverage of the drugs. Of course first you have to know what the drugs are that your doctor is proposing to treat you with.

A few corrections:

The new hepatitis C treatments that have now be approved by the FDA require the use of both injectable Peg-interferon and oral Ribavirin in addition to Sovaldi/Sofosbuvir or Olysio/Simeprevir in order to work at this time. These drugs are expected to not require peg-interferon and possibly ribavirin in the future but this is a transition period now. The only all oral treatment (Gilead's) that doesn't use injectable peg-interferon is for genotypes 2 and 3 ONLY.

Just so you don't have unrealistic expectations, there is no new or old treatment for hepatitis C that has an SVR rate of 90% for persons with genotype 1 and cirrhosis.

Sovaldi:
In Gilead's NEUTRINO study seventeen percent of patients had compensated cirrhosis and 89 percent were infected with genotype 1.
The treatment requires Sovaldi 400 mg once daily in combination with RBV (1,000 or 1,200 mg/day based on patient's weight) and peg-IFN (180 g/week). The SRV rate in "treatment naive" patients with cirrhosis in this study had a SVR rate of 80%. A huge improvement over the 14% SVR rate when using only Peg-interferon + Ribavirin alone which is all we had only a few years ago!

Olysio/Simeprevir"
SVR12 Rates in Treatment-Naïve Patients with HCV Genotype 1 Infection (Pooled Data QUEST 1 and QUEST 2) in those with stage 3 and stage 4 (cirrhosis) were 68%.


Best of luck with your treatment.
Hector
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YES can-do-man that is exactly what he wants to do.  He said there is no way I should ever go on Riba or Interferon again due to the bad sides.  He travels the globe attending the seminars on all new developments and feels really confident that this will be a success for me and many more.
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Avatar_m_tn
Fingers crossed that they will go for it and kudos to your doctor for giving it a shot... It has been done before with other Hep C drugs. Really wishing you the very best as treatment for you at this time is very important... Again, good luck.
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AASLD Meeting 11/06/13

COSMOS: Simeprevir plus sofosbuvir elicits sustained viral response

WASHINGTON – Results from a planned interim analysis show that using a combination of simeprevir and sofosbuvir as hepatitis C therapy achieved slightly higher sustained viral response in HCV genotype 1–infected patients at 4 and 12 weeks post treatment, suggesting that it may not be necessary to add in ribavirin.

That’s according to lead author 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.

Dr. Jacobson presented results from the four-arm, two-cohort, phase IIa COSMOS (Combination of Simeprevir and Sofosbuvir in HCV Genotype 1–Infected Patients) study. He reported on the final sustained viral response (SVR)12 for both arms of cohort 1 and the interim SVR4 for the 12-week arms of cohort 2. The two cohorts were enrolled simultaneously.
Patients were randomized to simeprevir 150 mg once daily plus sofosbuvir 400 mg once daily either with or without ribavirin for 12 or 24 weeks. Simeprevir is an investigational NS3/4A protease inhibitor jointly developed by Janssen R&D Ireland and Medivir. Sofosbuvir is an investigational nucleotide inhibitor developed by Gilead Sciences.

Cohort 1, with 80 patients, had a METAVIR score of F0-F2 and had previously not responded to pegylated interferon plus ribavirin.
METAVIR is an algorithm for establishing degree of fibrosis, with 0 being no fibrosis and 4 being cirrhosis. There were four arms of cohort 1: 24 patients received the triple drug regimen for 24 weeks, 15 received simeprevir plus sofosbuvir for 24 weeks, 27 received the triple therapy for 12 weeks, and 14 were given simeprevir plus sofosbuvir for 12 weeks.

* Cohort 2, with 87 patients, consisted of treatment-naive or prior null responders and those with a METAVIR score of F3-F4. In the four arms studied, 30 received triple therapy for 24 weeks, 16 received simeprevir plus sofosbuvir for 24 weeks, 27 got triple therapy for 12 weeks, and 14 received simeprevir plus sofosbuvir for 12 weeks. There was an even split in each arm between treatment-naive and null responders.

At the planned interim analysis, all patients in both cohorts had completed 12 weeks of therapy. In cohort 1, all patients – with the exception of three in the first arm and one in the second arm – had completed 24 weeks of therapy.
* All cohort 2 patients were continuing on study drugs, with the exception of two patients who discontinued triple therapy and one who stopped taking the combination of simeprevir plus sofosbuvir.

In cohort 1, 96% of those who took triple drug therapy for 12 weeks achieved an SVR12, compared with 93% of those on the dual-drug regimen. The SVR12 in those who received 24 weeks of therapy was 79% for triple therapy and 93% for dual therapy.

* For cohort 2, the SVR4 for dual therapy was 100% after 12 weeks of treatment, compared with 96% for the triple therapy. All treatment-naive patients achieved an SVR4 while taking either triple or dual therapy. All prior null responders taking dual therapy also achieved an SVR4, while only 93% of those on the triple therapy achieved an SVR4.

When looked at by HCV GT1 subtype, the results show that patients with the Q80K polymorphism did not fare as well. In cohort 1, 89% of patients with that polymorphism achieved an SVR12, compared with 100% of those with GT1a or 1b without Q80K. In cohort 2, 91% of those with the polymorphism achieved an SVR4, compared with 100% of the patients with GT1a or 1b who did not have Q80K.

The most common adverse events were fatigue, headache, and nausea. Adverse events occurred in 70% of patients in the 12-week treatment group and 90% in the 24-week group. Three patients had a serious adverse event.

Hector
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This is why I am hoping GramyA's doctor is able to pull this off, at her stage she needs to treat and all oral is her best shot...
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You are so right kind Sir!  The last attempt about killed me (as so many others can attest to the same)  My Dr. feels so confident that this plan will be successful for me, I so want to believe him.  My body is now finally feeling normal after almost a year out of treatment and feeling good so to think of dealing with any amount of sides again is unpleasant to say the least.  I do however feel like it might very well be one of my last hopes in achieving SVR and making it to a ripe older age.  I will be sure to let everyone know if the insurance approves the drugs and how it goes as I travel that road again.

Thanks to all of you for your time to respond to my posting! Blessings to one and all!
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I wonder if any rich rock n rollers that can afford the $170,000 plus Dr and lab fees might try this off label combo.  Of course as Hector pointed out the Q80K polymorphism test will help decide.  
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Good to see you back and still helping people! :)
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I have an appt. with my gastro doctor on Jan. 2 to see if I can get started on the all-oral Sovaldi (sofosbuvir) + ribavirin 12-week regimen (I'm genotype 2, treatment-naive). I have BlueCross Federal. If approved, I'll share the news with the forum.
Fingers crossed for all of us who have been waiting for this new drug!
Sue
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Treatment naive genotype 2s had a SRV rate of 95% is the FISSION study,
SOVALDI + RBV for 12 weeks.

Plasma HCV RNA values were measured during the clinical trials using the COBAS TaqMan HCV test (version 2.0), for use with the High Pure System. The assay had a lower limit of quantification (LLOQ) of 25 IU per mL. Sustained virologic response (SVR) was the primary endpoint which was defined as HCV RNA less than LLOQ at 12 weeks after the end of treatment.

FISSION was a randomized, open-label, active-controlled trial that evaluated 12 weeks of treatment with SOVALDI and ribavirin compared to 24 weeks of treatment with peginterferon alfa 2a and ribavirin in treatment-naïve subjects with genotype 2 and 3 HCV. The ribavirin doses used in the SOVALDI + ribavirin and peginterferon alfa 2a + ribavirin arms were weight-based 1000-1200 mg per day and 800 mg per day regardless of weight, respectively. Subjects were randomized in a 1:1 ratio and stratified by cirrhosis (presence vs. absence), HCV genotype (2 vs. 3) and baseline HCV RNA level (<6 log10IU/mL vs. ≥6 log10IU/mL). Subjects with genotype 2 or 3 HCV were enrolled in an approximately 1:3 ratio.

The most common adverse events (≥ 20%) for SOVALDI + ribavirin combination therapy were fatigue and headache.

I did this treatment for 48 weeks having cirrhosis and liver cancer and found the side effects minimal in comparison to peg-interferon and ribavirin treatment. I had headaches on and off for a few weeks and then fatigue increased over the 48 weeks although I never became anemic. It is very easy to take, 2 pills in the morning one at night.The recommended dose of SOVALDI is one 400 mg tablet, taken orally, once daily with or without food. The dose of ribavirin is weight-based (<165 = 1000 mg and ≥165 = 1200 mg). The daily dose of ribavirin is administered orally in two divided doses With food.

For someone treatment naive with genotype 2 chronic hep C this treatment seems to be what we would all could only dream of a few years ago.

Good luck with your treatment.
Hector
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Thanks for the info! Don't know if my insurance will pay for it or not.
I hope you're feeling a lot better. I'm glad to see you posting again!
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Avatar_m_tn
with or without polymorphism 91 % is still great . I highly doubt insurance will pay for sofosbuvir & simprevir , off label , your looking at $ 150 000 usd if you have the funds go for it if not you need to wait until end of 2014 for gilead and abbvie , next treatments will be cheaper as gilead will have competition .One reason of the high price of sofosbuvir is so people do not go off label , if it was say for example like $ 70 000 for the  simeprevir sofosbuvir combined many people would do it now even without  insurance assistance , I know I would .


In cohort 2, 91% of those with the polymorphism achieved an SVR4, compared with 100% of the patients with GT1a or 1b who did not have Q80K.
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Express Scripts Pushes Price Competition for Gilead Drug
By Drew Armstrong  Dec 10, 2013 4:07 PM ET- Bloomberg

The biggest U.S. drug benefits manager plans to start a price war over a new generation of hepatitis C treatments that will cost $1,000 a pill, in a bid to drive down spending on the medicines.

Express Scripts Holding Co. (ESRX) will pit Gilead Sciences Inc. against AbbVie Inc. (ABBV) and other drugmakers when the new treatments come to market next year or early in 2015. The new hepatitis C pills are projected to be among the biggest pharmaceutical sellers ever. While Gilead’s once-a-day drug may be the easiest to use, Express Scripts might block the pill from reimbursement if the competitors accept lower pricing.
......
Pharmacy benefit managers like Express Scripts control the list of covered drugs, or formularies, that get reimbursed or are subject to lower co-payments for patients. The companies force drugmakers to compete in an effort to gain discounts in return for making it on to their list, or for having lower co-pays to drive patients to the drugs.

excerpts above  - link to full story below
http://www.bloomberg.com/news/2013-12-10/express-scripts-pushes-price-competition-for-gilead-drug.html
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What wrong with this scenario? have dr. prescribe the Sofosbuvir + interf. + riba through insurance and  get a prescription for simprevir (cheaper than sofo from what i read on this forum) and pay out of pocket at pharmacy for it? Could this be done?
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Avatar_m_tn
Sofosbuvir + interf. + riba  prescribed for naïve not for treatment experienced so I do not think they would pay for retreatment
I think this is correct , I really hope I am wrong , does any body know ?
If I am wrong that is a great idea
Sofosbuvir + interf. + riba  with simeprevir would be a great combo
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HealthStat Rx: Curing Hepatitis C (HCV) With Confidence

ATLANTA --(Business Wire)-- December 12, 2013
One of the nation's leading medication therapy management companies, HealthStat Rx, announces today it offers Sovaldi™ from Gilead Sciences and Olysio™ from Janssen Therapeutics, to treat chronic hepatitis C virus (HCV) infection in adults.
.....
HealthStat Rx's national customer base includes hospitals, clinics, healthcare networks, home health care providers and patients with chronic disease. Healthtat Rx partners with patients and providers to drive superior outcomes.

Full article - http://it.tmcnet.com/news/2013/12/12/7591534.htm

FYI If your provider uses HealthStat Rx it may help. But only your insurance company can provide coverage information.
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Avatar_m_tn
I spoke to a hepatologist and he said that you could get on insurance
sofosbuvir & interferon & ribavirin under you insurance then pay out of pocket for simeprevir about $ 65 000 usd , sounds like a great deal
with this combo you have a great chance to succeed and really $ 65000 out of pocket is not a lot of money for your health
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$65.000 is a fortune if you don't have it.
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Yeah. You can't *get* $65,000 if you don't have it. I agree.
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That is an interesting article. It is entirely possible that maybe now in the 2013/2014 time frame, we're approaching the development of the perfect cocktail to combat the dragon, yet don't be surprised if the insurance giants and the chemical giants force some kind of competition that winds up getting tied up in court for months/years.
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Lab corp offers a new test to check for the Q80K polymorphism called the HCV Geno Sure drug resistant NS3/4 test.  Don't know the cost though.
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I called my pharmacy program and they have both Sovaldi and Olysio....said I would have a co-pay of $30/ea. Elbowed my way in for a 15 min appt with my hep dr armed with the results of Cosmos trial showing prior nul and naive of F3 and F4 with 100%. It's at hepititisnewdrugresearch.com.
He agreed to write off label for this Gt 1a, chirrotic with astices. Waiting for results of my Q80K polymorphism test....Quest offers it in addition to Labcorp.
Best news, ok a close second, is he said if I failed this I could re-treat with the 'miracle' Sovaldi/Ledipasvir  when it comes out.
2014 is looking to be a good year!!!
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Can you please tell me the name of your pharmacy program?
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Just an update - My Hep Dr. is putting ALL his patients that have failed at prior treatment attempts on this OFF Label cocktail.  He is convinced the 100% success result is real and will work for his patients also. The BCBS insurance I had denied coverage.  Ironically enough right after they did that my husband lost his job and we lost our insurance coverage so the doctor is filing for the drug companies to provide them free of charge.  FINGERS CROSSED!  He also said that there is no need for the Q80K test to be done when you are using just the Solvaldi and Olysio together.  He already has 2 patients on the program. Biggest know side effects are nausea, headaches, fatigue and of course anemia.  I pray this really is all that it appears to be and those 2 pills a day can kill this horrible disease.  I will update again when I have results of our attempt to get the drugs.
Blessings to all!
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Pharmacy program is Catamaran....healthcare provider is Aetna.
Hope that helps....
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That is great news from your hep and yes! Will pray they will cover costs. All indications are that they are doing everything possible to get this to the patient so have faith!
It's almost uncanny that you posted this. Going to sleep last night I was thinking about if Q80K came back positive and decided I'd ask if I could do it anyway. Results are 15/20% less effective but he also said I could re-treat with the Solvadi/Ledi when it came available so if in the meantime I could slow the process...why not?
2014 is going to be a great year! Blessings!
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So excited - today got approval for BOTH Solvaldi and Olysio to be provided to me for a 12 week treatment using just these 2 drugs!  As you might recall from my previous posts that my Hep Dr. believes that this combo will be the perfect cocktail for SUCCESS!  Tomorrow marks exactly 1 year since I stopped the last treatment at 24 weeks of Riba, Victrelis and Pegasus.  HORRIBLE side effects, blood transfusions and detectable AGAIN at the post 12 week mark.  It actually took me 6 - 7 months to shed all the side effects and feel normal again.  That was my 2nd attempt to SVR and at 61 years old I am really praying this treatment is indeed the final solution. I am 1b with cirrhosis.
I will be the 3rd patient he has doing this same program with many more trying to get approvals from their insurance companies. (other 2 patients meds were paid by Aetna)

PILLS ARRIVED!!!! I took my first doses last night and will post updates weekly on how I feel and the journey.
Keep the faith and blessings will often happen!  
Happy Grammy today for sure!!!
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That's great news.  Looking forward to hearing how you do on new treatment.
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Hoping you have good luck and My God bless you during this time. lots of prayers and keep the faith .
bbj
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Just wanted to get in the mix, I am starting a trial on the 15th of Jan, 14 by Bristol Myers Squibb. It is Daclatasvir, Asunaprevir, andBms#701325 . Not certain abt #. They tested these in Japan with good Eve's and now are in the States for phase 3. They are now hoping to boost the rate by addind ribivarin to the mix for half the participants in the trial, the remaining get a placebo . The RV will be a separate pill from the 3 part compound pill
. I did the Interferon/w RV for 68 wks in 2010-11 and virus showed at wk 68 after 42 wks undetected.  I'm just letting you know that this should be available within the not too distant future. By the way, I'm Geno 1 w/stage 4 compensated and been hcv pos. for 40 yrs. Anyway,what ever happens I hope each and every one of us gets thru this w/ a few coins left in our pockets.
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How are you doing?
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Thank you for asking - I am REALLY GREAT!!  Today marks the 1 week mark since I started this treatment plan of JUST 1 Sovaldi pill and 1 Olysio pill per day!  I still cannot believe I went through that 6 months of hell treatment with the Incivick Triple Treatment.....and this one is sooooo much easier.
So far, only 2 things have occurred ..... about a half hour after I take the pills I get a hot flash.  Just one then it is gone.  The other thing was a few days ago I got a headache that came on and within an hour hit a level 8.  I took one extra strength Tylenol and within 15 minutes it was completely gone.  Chemical headache chased off by another chemical perhaps.  Just hoping that this cure will work throughout the entire 12 weeks of treatment if it is needed.  My energy is great and looking forward to this working!!!  I will post again in another week for those of you that want to track my progress.  
ALL OF YOU are in my prayers too!
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Thank you for responding! Are you supposed to take them with or without food? Prayers for you too!!;)
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Hi Faithdove,

One of the pills requires it to be taken with food so I take both of them together at that time with my dinner.  None of that horrible 20 grams of fat nonsense that went with the Incivek treatment..... thank the Lord!
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Really happy to hear your positive first week tx update.  Glad Sovaldi and Olysio were provided to you off label for free by Gilead & Janssen.  You are very lucky to have that Hep doctor.
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Thank you!!
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I'm reading a book called "Grain Brain" that is pretty solid in suggesting that many headaches can be avoided by avoiding food that contains gluten.
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I am reading that book too!! Very interesting
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May I ask where you live and how you got on this trial?  My husband is 69 has not been a candidate for the Peg treatments, but is stage 4 and really needs this less rigorous treatment as soon as possible.
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GrammyA didn't get on a trial. She was very luck that her doctor prescribed Sovaldi and Olysio off-label. Because she lost her insurance the doctor was able to get the drug companies to provide the meds free.  See GrammyA post  Jan 05, 2014 & Jan 11, 2014 above

BTW if you hover over a members name or click to go to the members profile.. If they have provided a location you will see it. It may not be currently correct if they haven't updated it
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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!
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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!
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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....
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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!
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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
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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.....
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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
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Avatar_m_tn
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
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Avatar_m_tn
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
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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.
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Avatar_m_tn
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.
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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
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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?
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Avatar_m_tn
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.  
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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
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Things might tighten up a bit for those that "just want it"
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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?
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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,
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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
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Thanks Mark.  This medicare stuff is overwhelming and your answer help me understand my choices.  Good luck with your treatment.....
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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.

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Check out "Wheat Belly" also
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