Getting assistance with Sovaldi on Medicare, Medicaid, etc.

[hepcat1954]

Good news!

For those on Medicare, Medicaid, etc., you CAN get assistance with Gilead's Sovaldi from the Patient Access Network (PAN).

https://www.panfoundation.org/

The specific application is found here:

https://www.panfoundation.org/fundingapplication/index.php?8

Their phone number is 866-316-PANF. You can also apply by phone.

Yay!!  Merry Christmas!

HepCat

...

[hepcat1954]

For those with private insurance, go to

http://mysupportpath.com OR  https://www.sovaldi.com/register.aspx

for assistance paying for Sovaldi.

HC
...

[hepcat1954]

https://www.panfoundation.org/hepatitis-c

Hepatitis C Program Status
Open - We are accepting applications for new and renewal patients. If your application for assistance is approved you can begin receiving funding immediately.

Maximum Award Level
$7,000 per year

Eligibility Criteria
1) Patient should be insured and insurance must cover the medication for which patient seeks assistance.
2) The medication must treat the disease directly.
3) Patient must reside and receive treatment in the United States.
4) Patient’s income must fall below 500% of the Federal Poverty Level.

Click here for Federal Poverty Guidelines
http://www.familiesusa.org/resources/tools-for-advocates/guides/federal-poverty-guidelines.html

Get Help With Your Treatment
Apply Online http://www.panfoundation.org/fundingapplication/index.php?7 or call 1-866-316-PANF (7263)

Information About the Disease
Hepatitis C, like other forms of hepatitis, causes inflammation of the liver. The hepatitis C virus is transferred primarily through blood, and is more persistent than hepatitis A or B. High-risk groups are people who inject drugs, people who receive transfusions of unscreened blood, dialysis patients and people who have unprotected sex with multiple sex partners. Hepatitis C is also treated with antiviral medications.

For more information visit the Hepatitis Foundation International website, or call 1-800-891-0707

[hepcat1954]

The PAN cover both Sovaldi (Sofosbuvir from Gilead) and Olysio (Simeprevir from Janssen)...

Both of these are on the market NOW and many are taking a combo of these off-label.  Talk to your doctor...

[JimmyMose]

FYI For those on Medicare, Medicaid, etc - Does it have to be added to the "Formulary" of your insurance company?.  Can anyone on Medicare, Medicaid, etc confirm coverage now?

Who on Medicare, Medicaid, etc will get this expensive treatment?  Will there be restrictions that only those who meet certain medical criteria will get it in the near term and others will have to wait?  Will it cover off-label.use?  

The above is required before .panfoundation.org coverage.
1) Patient should be insured and insurance must cover the medication for which patient seeks assistance.

[hepcat1954]

I would think yes since this is a Baby Boomer disease but I'm trying to see if I can verify that...

[hepcat1954]

It looks like it depends on who you use for Medicare Part D?  (I'm not on Medicare so this is all new to me.)

According to one Part D provider (Providence), they usually add the drugs on January 1st each year.  That's why Sovaldi and Olysio getting approved in December is good timing.

Can the Formulary change?

Yes, Providence Medicare Advantage Plans may make certain changes to our formulary during the year. Most changes in the formulary happen at the beginning of each year (January 1). However, during the year there may also be changes. For example, the plan might:

Add or remove drugs from the Drug List. New drugs, including new generic drugs may become available or there is a new use for an existing drug. We may remove a drug because it has been found to be ineffective or there may be a drug recall.

Move a drug to a higher or lower cost-sharing tier.

Add or remove restrictions on coverage for a drug. (for more information about restrictions on drug coverage, refer to your Member Handbook/Evidence of Coverage)

Replace a brand-name drug with a generic drug

https://healthplans.providence.org/medicare/pharmacy-medicare-part-d/pharmacy-guidelines-faq/Pages/default.aspx#change

I guess folks should check with their Part D provider...

HC

[lklucky]

I have to sign up for obama care tomorro.. start my treatment in mid january and don't wanna wait any longer..but if anybody has signed up for obama care can you help me out.. trying to get everything with meds don't wanna be turned down somewhere or for something I need because of the obama health insurance I picked..n knda worried finicially how much the meds and treatmnt cost if nebody went thru it w ****** insurance..lmk asap!

[pooh55811]

I did not sign up for health insurance through the new health exchanges. However, a friend of mine did. This is what he said:

Spent all day reading and comparing the plans in the platinum tier.  All I can say is if you dont know how to do the math you will have a problem!  The lower premium plans will definitely cost you more throughout the year because they have additional % attached to them in out of pocket maximums.  One plan didnt even have an out of pocket maximum.  So the one I chose had  no deductible, $2000 max for medical, and $2000 max for prescriptions, and small copays for Drs."

His plan was in the platinum tier and cost $644 a month. From what I have read, be very careful of any of the plans below the silver tier. They may have lower monthly premiums, but they get you in deductibles and co-pays and other areas of coverage (or lack of coverage). Plus, it appears that there can be Federal help for some if they choose a silver plan instead of a bronze plan.

"Under the law, there are special provisions for lower-income Americans who purchase a silver plan but not a bronze plan. People who earn less than 250 percent of the poverty level – about $28,700 for an individual – get extra help from the federal government in the form of lower copayments for doctor visits and smaller annual deductibles. For the lowest-income residents, that can mean plans with little or no deductible and copayments as small as $3 for primary care doctor visits. “Be very careful before you take a bronze plan over a silver plan” if you are in the subsidy-eligible income range, said Linda Blumberg, a senior fellow at the Urban Institute. Those earning less than twice the federal poverty level, about $23,000 a year for an individual, get the most help, with subsidies ratcheting down sharply after that."

Now that quote is from a newspaper article so I cannot be sure it is accurate. However, keep it in mind when looking for a plan.

http://www.nbcnews.com/health/consumers-beware-not-all-health-plans-cover-doc-visit-deductible-2D11794861

Just be very careful choosing a plan and do the math. One plan may have a low monthly premium and yet have a high deductible and co-pays. That type of plan would cost you a lot more in the long run. One always needs good health insurance because one never knows when something is going to happen or an illness will appear. In addition, you already have Hepatitis C which is an expensive disease to treat. You will have many doctor visits, many lab tests, expensive medications, and possible unforeseen complications or medical needs. In addition, not knowing your liver fibrosis stage, if you have Cirrhosis, you will need to be monitored very closely by a Hepatologist. This all adds up in terms of costs.

So compare the plans closely and do the math. You do not want any financial surprises while you are on treatment. If you have a low income, see if you qualify for the Federal assistance.

Best of luck.

[pooh55811]

I might add, if you have further questions about Hepatitis C you may wish to start a new thread by gong to the top of the page and clicking on the orange rectangle "Post a Question." Then put in a subject line (title) and ask your question. More people will see it and respond if you start your own thread.

[Janee56]

I am on Medicare or rather a Medicare Advantage plan.  The Formulary was released already for 2014 along with addendums and our new med is not on it.  I posted a similar question on medhelp and didn't get an answer directly, responses yes:)...but here is my experience:  I received a phone call yesterday from the specialty pharmacist.  They're working on my paperwork for me, and to get a formulary added takes about 2 to 3 weeks.  If it is approved. I will notify medhelp group as soon as I find out. The government must be made to understand that it is cheaper in the long run to treat the virus.  Please understand that this will only add the formulary for me personally.  you must each go to your doctors or pharmacist now and do this. While we may get lucky and my approval counts for everyone, I certainly would not bank on that if I were you. The formulary will be mailed to you and You can also get a copy on the web. It thoroughly explains how to get a formulary added for your case. Please stay in touch. Janee

[hepcat1954]

I thought new drugs could be added during the year, as you've stated.  And since everyone has a different Part D plan, is that the reason for doing it individually?

Thanks!
HC
...

[WVPatient]

Regarding Solvaldi,

You say that you can receive up to $7000 a year in assistance. Solvaldi is $84,000 for the 12 week program. I don't mean to sound annoyed but how does covering $7000 out of $84,000 help someone with no money?

[klonny55]

That's only one option of many. Gilead (maker of Sovaldi) has programs to help and will provide meds free of charge to those who can't get them otherwise. Go to supportpath.com and speak to someone there. Tell them about the particulars of your situation. I found them to be very friendly and helpful in my case.

[Upbeat]

The 7000 covers the copay that is not covered by medicare or your part D drug plan. I got the 7000 grant last week and I received My Sovaldi script for free.

[JimmyMose]

Maximum Award Level $7,000 per year for Medicare, Medicaid, etc doesn't mean you will pay the rest. Depending on your circumstances if you are pretty poor your copay's will probably much less than $7,000 total.

Medicare

The drug has to be added to your plan's formulary and the doctor has to get pre-approval including documentation why the brand name drug is needed. If not on the formulary or for off label use a documented special form must be submitted for approval. An answer has to be given within 3 or 4 days unless emergency.  If denied it can be appealed.

From what I read some have received coverage as non-formulary or off label through that process. I personally don't know of any medicare insurance companies that have added it to their formulary yet.

Even if you are denied including fast tract appeal and your medical condition warrants treatment now or very soon.  I'm guessing your doctor could still directly request the drug companies to provide the medication to you.


This post was moved from here to the Hepatitis Social Community
Formulary Lookup Tool - US drug status for health plans
http://www.medhelp.org/posts/Hepatitis-Social/Formulary-Lookup-Tool---US-drug-status-for-health-plans/show/2091595#post_9914883

Depending on your plan you will pay deductible and or co-pay up to the  "donut hole"
https://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html

Catastrophic coverage
Once you've spent $4,550 out-of-pocket for 2014, you're out of the coverage gap. Once you get out of the coverage gap (Medicare prescription drug coverage), you automatically get "catastrophic coverage." It assures you only pay a small coinsurance amount or copayment for covered drugs for the rest of the year.

You also may qualify for extra help for part D see links on left side on the link provided above.

I'm not sure about Medicaid depends on your state but somewhat similar.

Hopefully we will know more over the next few months. it may not be added soon to many of the plans formulary and special requests and appleas may have to be made.

I GUESSING  there will be a lot of resistance to treat with the new expensive drugs for those who are pretty healthy with F0,F1 or F2(without other problems). If medical condition is such that treatment is need now will hopefully will get it quick. Those in the F2+ or F3/F4 hopefully within the next year. The rest with low chance of much damage in the next 2 or 3 years without treatment may have to either offered the older treatment or wait for a couple of years until more competition brings the price down.  

[WVPatient]

TO ALL THOSE WHO REPLIED to me:

1. Thanks.

2. So let me understand you correctly:

My wife is on Medicaid. I have private insurance paid for by my parents. My wife and I have no income at present.

Are you all telling me that she will be able to get treatment, basically for free? Medicaid is going to pay for a $1000 a day pill? And/or Gilead will pay? If I haven't given you enough info to give me a better answer, what information do you need?

Thanks.

-Alex

[JimmyMose]

No one is telling you that she will be able to get treatment, basically for free?  I can not answer that question.

Your wife's doctor's will have to recommend treatment and submit to her Medicaid plan to see if they will cover it.  If not your doctor and you will have to file and/or appeal. If they will cover then you will be told what your co-pay will be.  

Then if you can't pay that you would then apply here
Patient Access Network (PAN).
The specific application is found here:

https://www.panfoundation.org/fundingapplication/index.php?8

If Medicaid coverage is denied and the appeal is denied and your doctor felt that treatment was needed to be started soon then you and he could try to directly get the drug companies to provide it free.  Financial documentation will be needed.

You haven't mentioned anything about her HCV condition, genotype fibrous status blood test symptoms etc.  My guess is that if her condition is good with no (or low) fibrous or other complications she may have to wait a couple years for the new treatments to be covered by Medicaid.  Some better private plans are already covering the new treatments.

I am genotype 2a,2c F3 and my VA doctor just told.me that I can probably start Riba and Sovaldi for 12 weeks within the next month or so.
The VA negotiated a price of about $650 per pill (unofficial) My copay will be either $0 or $18 a month  (I am still calculating my low income for last year )

Good luck

[klonny55]

Hi Alex,

I am in Vermont, genotype 2, 11 days into 12 weeks of Sovaldi/Ribavirin. I am recently enrolled as of Jan 1, 2014 into Vt's medicaid expansion program. Medicaid approved my prescription after initially denying it. We didn't go through an appeal exactly, more an informal reconsideration. My doctor totally went to bat for me and evidently was convincing. My copay is $6 a month. I was in touch with Gilead during this process and they assured me that they would provide the meds for no charge if Medicaid ended up denying an appeal. In order to receive free meds from Gilead you need to make less than 500% of the federal poverty level income. That's $77,500 household income for a family of two. They count the income of everyone under the same roof and all of their income. The $77,500 number goes higher if there are more than two people living under the same roof, but they also count any additional income. Medicaid also uses household income to determine eligibility. Anyone who qualifies for Medicaid would certainly qualify for Gilead's assistance. I hope this makes sense!  Best, Dave

[klonny55]

I should add that the process goes like this: Your doctor prescribes the meds and sends the prior authorization application to Medicaid. They either approve or deny. If they deny there is an appeal. If the appeal fails then Gilead steps in with the free meds.

[JimmyMose]

That's great that you got coverage and low co-pay. Vermont is one of the best states for coverage.

WVPatient What state are you in? it can be different for each state and each persons medical condition.  The only way you will find your answer is for your wife's doctor to do what klonny55 and I mentioned.

I wish you the best.

http://www.webmd.com/health-insurance/medicaid-health-care-people-low-incomes
"Although the federal government sets up general guidelines, each state runs its own Medicaid program. States establish what health care services are covered and which groups of people get coverage. As a result, Medicaid programs vary a great deal from state to state."

Where the states stand on Medicaid expansion
25 states, D.C. expanding Medicaid
12:44 PM - February 7, 2014
http://www.advisory.com/daily-briefing/resources/primers/medicaidmap

[Savannah12]

I am on medicaid and I am approved for Sovaldi/Olysio with $0 out of pocket costs. Previous partial responder 3x interferon/ribavirin though, treatment naive requires interferon with sovaldi and riba.

[JimmyMose]

Great to see another member covered for off label treatment by Medicaid.

BTW what state do you live in?

Most states have managed care, Medicaid recipients are enrolled in a private health plan. Core eligibility groups of poor children and parents are most likely to be enrolled in managed care.  While the aged and disabled eligibility groups more often remain in traditional "fee for service" Medicaid.  It varies so much from state to state

[Savannah12]

I am in Connecticut. I was told by the pharmacy that people with medicaid were being approved within an hour, however people with private insurance are being denied and are stuck going through appeals. I was so shocked when medicaid approved $150,000 of off-label tx.

[WVPatient]

Dear Dave,

That's fantastic news and information. Thank you.

-Alex