Has anyone had any experience with Medicaid and Sovaldi? My prescription was written on Monday of this week for 12 weeks of Sovaldi and Ribavirin. I have registered with Gilead at supportpath.com. But now my hepatologist's office is saying that getting Gilead involved may complicate things. This is after they handed me the little welcome kit (!) from Gilead saying I should register. I am newly enrolled in Medicaid as of 1/1/14 through my state's Medicaid expansion via the Affordable Care Act. I am wondering why would the state pay for it if they know that Gilead will provide it free of charge if they refuse? But then isn't Medicaid supposed to cover any FDA approved drug that meets the clinical criteria of the condition being treated? I am genotype 2b, treatment naive, F2-F3 fibrosis and asymptomatic. I am hearing from my hepatologist's office that insurance companies are giving them a hard time with Sovaldi. I am a bit on the edge of my seat on this one. I'd really like to get started with this!
I haven't had any experience with Medicaid or Medicare but I believe some member have or have knowledge and will reply.
There are so many variables and it may depend on the state coverage requirement what plan you are enrolled in.and how they make that decision.
Most likely my guess is that new or even all Hepatitis treatment drugs may require Prior authorization
A very limited list of some things I found when searching.
Prior authorization means that before the plan will cover the drug, your doctor must contact your drug plan and let them know that the drug is medically necessary. Some drugs cost more than others, and often a cheaper drug might work just as well. Still other drugs may be safe, but work only for limited amounts of time. To be sure certain drugs are used correctly and only when really needed, Medicare drug plans may require a prior authorization. se requirements may help to ensure that drugs are used properly and that they work as intended. But they require your doctor to take extra steps when prescribing the drug, and it may take longer for you to get the drug from your pharmacy. Because each insurance plan varies, doctors sometimes don’t know that a drug requires prior authorization. Like you, your doctor may only find out after you go to the pharmacy and then you or the pharmacist call the doctor back.
Also referred to as a fail-first requirement, the step therapy restriction denies payment for a drug unless certain other drugs have been tried first. For example, the plan may cover a drug like esomeprazole (Nexium®) for heartburn only if the patient did not respond well to cheaper drugs. So a patient might first be treated with generic omeprazole (Prilosec®). If this drug doesn’t work well, coverage for a more expensive prescription dose of generic lansoprazole (Prevacid®) might be approved. And only if those drugs have been tried and didn’t work would coverage be approved for a
brand-name drug, like Nexium.
Some members here have already reported some insurance plans covered treatment with the new drugs even off label. But those were prior treatment non-responders or Peg intolerant, mostly GenoType 1 and other conditions etc.
For those with Hepatitis C genotype 2 treatment naive some plans may deny and require treatment with Peg and Ribavirin because treatment SRV although not close to 90% like what was said a few years ago but still near 80%. So you may have to appeal and your doctor provide a strong case why you should be on the new drugs. In a desperate real situation there may be a fast tract 72 or 96 hours request.
There is 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. The max depending if you qualify and the amount is limited to $7,000 total if available at the time you apply (it is now)
NOTE again this is only my guess and personal opinion
I don't have a personal experience with Medicare however this is from a VERY reliable source...."just got off the phone with Gilead. All patients are covered. Medicare patients require nothing more as long as you do not have Medicare Part D (prescription coverage). Then you will have co-pays but not a lot of money!....Private insurance will require co-pays but if you cannot afford same, you will get help!!! There is no patient population that will not be able to get Sofosbuvir!" (Sovaldi)
Hope that helps!
Hi Jimmy,Thanks for the reply. The prior authorization has been submitted by my doctor's office and we are waiting for the response. I have been assured by Gilead through supportpath.com patient services that if Medicaid denies coverage of Sovaldi they will appeal on my behalf. If the appeal fails then Gilead will provide Sovaldi to me at no charge. The only requirement is that my income is within 500% of the federal poverty level which is not a problem.
I'm not so much concerned that I will have to do the 24 month Peg/Ribavirin treatment as much as I am about how long it will take to get through the scenario above if it comes to that. It's only been a few days so maybe I need to take a deep breath and trust the universe.
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