Q. re. insurance and 72 week extension

[Marc1955]

I'm wondering what other folks experience has been with getting insurance coverage (in the U.S.) for an extension of treatment to 72 weeks. I was just turned down by my insurance company. I can understand why – I think the only current FDA approved treatment is 48 weeks so they certainly have their justification. I'm hopeful that I'll be able to reverse the decision upon appeal.

But I'm figuring this must be pretty common. Or am I the only one with a difficult insurer? Did the folks who are doing 72 weeks get approved at the beginning or did they get an extension somewhere along the way? We talk a lot on this board about extending to 72 weeks but I haven't seen much discussion of the insurance difficulties it might entail.

[Proactive]

Hello Marc,
This has been discussed in the past, so it may be worth your time to do a search...I was denied treatment extension, but I believe that is not as uncommon as one would think, for the very reason you mention
(it isn't standard care).I did win the extension decision on my appeal. I supplied my docs office with study data (Berg's study etc.), they used it to file the appeal and ulimately won. But and this was a big but, I was fortunate that my doc's office had available meds on hand or I would have been without during the appeal process..I will note though, that Schering assistance did offer me an emergency 1 month supply of the drugs...I needed to send them a copy of the first denial letter and a written script from my doc. Which brings us to the subject of getting assistance from the drug manufactures. In scherings case (pegintron) they would have covered my treatment drugs for the extension..
There were some financial qualifications (which were very generous) and one needed to be denied twice on appeal and supply the letters of denial, but in the end they would have given me 24 weeks more of drugs..

So keep on top of the appeal process, insurance co and your docs office. Call for emergency meds now from your manufacturer...you don't want to run out.
Pro

[nygirl7]

I was denied way back about three years ago or so - they said it was "experimental" even though I didn't clear until 12 - 24 somewhere and had two geno 1s (a & b).  That isn't that bad a thing Marc. Now all you have to do it go to Comittment to Care (PegINtron) or Pegassist (Pegasys) and call them. They WILL pay for both the peg and riba and mail it directly to your house every month. All they ask is for the denial letter and then contact your doc and he writes the script. While it's all waiting to be approved they just SEND you a months worth of meds - even before it is approved. Once they get that denial then you just call them every month like you would a regular pharmacy and they ship it out to you - F.R.E.E.

They made it SO easy for me it was ridiculous. They are happy and nice and WANT to give you the meds.

Just google up their phone numbers and call them right now.  It's amazing. The insurance WILL continue to pay (mine did) for the doc and PCRs and everything (even the ambien's and procrit) and test and everything they just wouldn't pay the tx meds.............

So it should work out just FINE for you.

CALL NOW!

[nygirl7]

PS They did have my doc write an appeal letter - that was technically the second denial....but believe me those insurance companies are gonna deny it - that is why they give you a month of free meds off the bat.

And yes they ask you your income but they are VERY generous.......it's not like you have to be in poverty level, I actually make a healthy salary and they approved me with no problem and never even made me submit anything saying what I made.......they just took my word for it :)  Couldn't believe that that is how much they do want to get the meds for you.

[meakea]

I'm sorry to hear you are having insurance problems.  

The only thing I might suggest is that you consider consulting an attorney if the insurance company continues with their BS!  There are legal issues involved with denials and it's not just a matter of them being able to deny, deny, deny...they have to account for it.

[FlGuy]

I'll echo what Pro wrote.  If you insurance is like mine, they have rules and procedures and you'll probably need to play along.  Thing is, you can not expect the doc and the insurance company to stay on track without you guiding the way and making sure things keep moving.  Don't be a pain in the butt to anyone, you never know who can sink you with inaction.  Make sure they continue to want to help you.

Pro's point about maintaining a supply of meds is important.  You can't get caught in a med gap otherwise you may quickly defeat the purpose of extension.

[Bill1954]

Pegassist (Roche Pegasys system): 1-877-734-2797

Commitment to Care (Schering- Plough PEG-Intron system): 1-800-521-7157

[merryBe]

sorry to hear about your troubles, my docs told me there could be trouble with insurances but so far mine has been very good. It's Blue Cross regence. I also took studies in, and asked them to use the studies if I was denied. My doc was glad to have the studies, and said they come in very handy when ins. balks.

However I agree tou need help now, not weeks from now, and should call the companies in the interim.

I also think you should reveal which insurance you currently have. It would help others to know which insurance companies are resistant to current medical thinking, whether the FDA has kept pace or not, we all need our insurances to respond possitively especially when extended care can give similar rates of SVR to late responders.

mb