insurance problems are starting...

Hi All! Quick background:  Geno 2b gastro doc original tx plan was 24 weeks, I didn't become UND until week 11, so doc extended my tx to 48 weeks...well now Blue shield says they will not authorize anymore meds because the standard is that 2b treats for 24 weeks!!! What happened was that my authorization ( not refills ) expired so my doc put in to get re-authorized. My doc is appealing and is also upset by this as he keeps current on different studies and feels that my chances of staying clear of the virus depend on how late I became UND and how not every 2b fits into the standard of 24 weeks. I have enough meds for about 2 more weeks...I want to call Shering Commitment to Care but am afraid I may not meet income requirements. Me and Hubby are middle income but there is no way we can afford to pay for these meds. Help!! Just needed to vent, I don't want to stress too much about this, I'm glad I have insurance but why are these greedy insurance companies ignorant to whats current with hep c.

[blakcat]

Thanks, I hope the my doc gets positive action on this, I'll let you know...

[welderman]

You dr should be able to appeal it the only problem some times it takes a little time. I had the same problem with blue shield my dr was going to start me on peginton because of my size and weight. I'm a 6'5" 270 lb  with the pegintron he could wieght base the dose for me. But my Ins co came back and said only pegasys was there approved drug for geno 2b's My dr said he could appeal it and has with success but decided to go with the pegasys and up my riba form standard 800 to 1200 mg a day good luck I hope your dr can get it done for you. I would also call shering


Lynn

[ladybug52]

How long have you treated and how much longer do you need to treat? Are you doing the redi-pen and riba? How much ribavirin?
Bug

[BThompson4]

I would definitely contact Commitment to Care (1-800-521-7157).  Their qualifying incomes are surprisingly liberal, especially if you have children in the household.  

You will probably get an answer to whether you qualify the first time you call (they strive to provide fast phone service), since their requirements are very simple and straightforward.  The only financial data of yours that they look at is your most recent tax return.  You could have lots of financial assets but I am pretty sure that approval or rejection rests on the qualifying income for the state you reside in and number of dependents on your federal tax return.

I think they really want to give some of these meds to people, in part, because they might send peg to people who qualify that is due to expire anyway in a month or so, and people really do not like to pay huge amounts of money for drugs that are slated to expire soon.  

I know when I get peg through my insurance company (20% copay is pretty substantial) it is always dated to expire in about 18 months; the couple of times I have received it free from Schering-Plough it had an expiration date only a month or two in the future.  

I look at it as a program that creates great good will for the company and helps with their inventory control.  Because of the nature of treatment, they probably make way more than they expect to sell, because the consequences would be catastrophic if they ever ran out for some reason.  Can you imagine what would happen to your treatment if they ran out and could not supply you with peg in week 36 of your 48 week treatment!

Hope everything works out for you.

[nygirl7]

I too thought they would say I was well over the income level but they didn't.  In fact C2C never really asked me for any hard copy proof of what I even made!

All they had me do was get a copy of the insurance denial letter and then ask the doctor to send the insurance company a letter of appeal (just saying why he thinks you need to extend).

Then...after that first phone call before I had the chance to even start doing anything - they called my doc and got a prescription and sent me a MONTHS WORTH OF THE MEDS - BEFORE I WAS EVEN APPROVED FOR REAL!

They are unbelievably great!  I extended from 48 to 72 and my insurance company said it was "experimental" so they denied me too.

C2C made sure my meds came the ENTIRE time I extended - straight to my house - NO cost at all, not even a copay.

You just remember to call once a month to their "pharmacy" (same number ask for pharmacy) and ask for your refill and the meds will be at your house in a day or two.

You can't beat it.

Don't be afraid to call - they are REALLY awesome, pleasant and they WANT to help you.  I couldn't believe it, they were just that incredible and easy to deal with.

Good luck!
Debby

[FlGuy]

This is not something that just your doc gets involved in.  You need to be taking some action.  A starting point for you would be to make contact to the 'member number' on your insurance card.  Making sure that you have any letters or notices that the ins. co. has sent out denying continued coverage of the meds.  You need to work the phones on your part, as the doc is working from his angle.  Don't just wait for stuff to happen, make it happen.  You might be making an investment of time and frustration with the time you might have to spend on the phone with your insurance company, but it's worth it.  Take notes, get names, understand the hoops they expect you to jump through - but work it.  This could be a fairly simple matter to resove.  But if you only have a few weeks of meds left - there is a time factor involved.

[elizabethanncothron10/9/63]

gosh, i know what u mean. iv'e worked my whole life, paid taxes, & this is what i get! i had 2 quit work so insurance ran out. i'm recently divorced. from an idiot that won't help, so i had 2 apply through the state of michigan, where i now live. i practicly had 2 beg 4 it. but i finally got it. but it doesnt cover alot of my meds. the first meds my dr. put me on it wouldn't cover. so had 2 go 2 the only other 1 there was. it finally covered that1. i'm in the middle of my disability case right now. i have 000000 income. it's freakin crazy. i thought the government was supose 2 help people. espeicially those who have a work history. all i can tell u is don't give up, & good luck & god bless.  elizabeth

[blakcat]

Thank you everyone! I need 4 months more of meds, I'm definitely gonna call the Shering program, I'll let you guys know how things go...I actually feel a lot better and not too stressed out, whatever happens will happen for a reason...Hope everyone has a good weekend!