Anyone know if Insurance will pay for these new drugs?

[GrammyA]

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?  

[NYCMark]

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

[somuchmore2]

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,

[primaburgess]

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?

[can-do-man]

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
------------------------------
Things might tighten up a bit for those that "just want it"

[JimmyMose]

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.  

[taominatrix]

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?