telaprivir not covered

I have heard that the telaprivir might not be covered in the insurence when it comes out,Is there any truth to this?anyway let me know.

[neptune235]

Telapravir, once it is approved as a treatment for HepC by the FDA, will be covered, as required by law.

[FlGuy]

Required by law?  How do you arrive at that statement?

[neptune235]

It's not legal for health insurance to deny an FDA approved treatment when prescribed by a physician.

Do you think this isn't the case?

[SusieS2010]

I'm not sure where you got that understanding. An FDA apprpoved drug, can be denied by an inusrance company. The doctor can always fight that for the patient, and often the pharma company will get the drug for the patient through it's patient assistance program, BUT there is nothing illegal about insurance companies denying coverage....unfortunately.

[neptune235]

Actually, that's not quite correct.  They make you jump through hoops, they may require you to attempt other treatments, but if you qualify (and by that, I mean under generally accepted medical guidelines, and with FDA approval), ultimately, you will prevail.

This only got easier under HCR.

Do you recall any new AIDS drugs getting FDA approval, but being denied, en masse, by insurance companies?  It just does not happen.

And for the record, there is PLENTY wrong with insurance companies denying coverage.

[Bali05]

as far as i know it will be covered  but ONLY for geno 1 .
every other geno will be considered OFF LABEL

[neptune235]

Don't forget the financial motive the insurance companies will have to pay for this.  Within a couple of years, the push by ins co's to shed their sick patients will by and large be over.  The risk pool will be stablized, and then the fact that TPV will increase SVR rates from 40% to 70% (or whatever) will be sound financial motivation for them.

SOC will, upon FDA approval, change to a triple cocktail including the current SOC, and and the addition of one of the PIs.

I really think that people who believe otherwise are being unnecessarily alarmist over the issue.

I s'pose I could be wrong, but...well, we'll see.

[neptune235]

True, that if it is off-label for genotypes other than 1 it will be more difficult to get them to cover.  They may refuse and get away with it.

Although, historically, insurance companies will approve off label use for HepC.  Label directions for Infergen is 9 or 15 mcg thrice weekly -- but there are plenty of people here who have gone through daily courses paid in full by insurance.

Again, we'll see...but for sick patients labeled use will be pretty tough to deny, I would think.  What would the justification be?

[Bill1954]

Hypothetically, it seems the actuaries might reserve payment to those that have tried other means and failed; as in previous null responders to Standard of Care? That happens frequently in other situations. Does anyone have knowledge that protease inhibitors will be approved and adopted as first line standard of care?

For instance, payment for Infergen is often denied initially; only when other measures have been taken is it generally allowed.

Hopefully, the new drugs will be shelf available across the board, but I personally have now knowledge of this—

Bill

[SusieS2010]

I do know what I'm talking about. It happened to me personally two years ago. I also did not say there is nothing wrong with insurance companies denying coverage. I said there is nothing ILLEGAL. I was denied coverage by BS/BC's pharma plan that we used under my employer. We went through the whole appeal process. We were turned down for both appeals. We actually went to court and lost. I finally got what I needed through the compassionate care program of the manufacturer. Again, an insurance company can do what they please. That is a lot of what is wrong with them today.

[neptune235]

I hate insurance companies.

[SusieS2010]

Me too. And don't I remember a few years ago that 10 or 12 NY State insurance companies denied single access drugs to HIV patients who needed them deperately? I think I remember some Senator fighting to get a bill passed so that NY patients could get these drugs that are for HIV and have no generics.

[orphanedhawk]

Mike, Why worry about ifs?

It's been my opinion for some time that the mafia transformed the protection racket making it legal by calling it insurance.
Health care should be about health and caring, not about profits.