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4896357 tn?1360674504

I Have Best Insurance - Tx Still Denied

So, I purchase the very best insurance through the ACA web site. Blue Cross, Blue Shield Premier Platinum Extra with Dental and Vision. It costs me $1,157.00 per month for just me. They denied my Harvoni. They also have a one year wait for any major dental coverage. That must have been buried in the fine print. We will appeal and then seek assistance from the drug company. I'm still very pissed off right now. The ACA is a bad joke and our president is a bad joke. >_<
21 Responses
2059648 tn?1439770265
So what hepatitis C treatment will your insurance cover?   Has you doctor appealed yet?  You are in the processes of getting approved for treatment.
Filing an appeal is often part of that process.   You have to be denied and appeal sometimes  get to where you want to be.  It's often part of the insurance process.  I have had the same insurance for over 20 years.  When you don't like what they say you appeal.  Often you can get a denial on an expensive drug like this.  If you just except the outcome the insurance company saves money.  Appeal....you could be denied again...then go directly to the drug company.  

Hope this helps
4896357 tn?1360674504
Yes, the appeal process has been started. I had been told that this premium insurance was approving Harvoni with no hassles though. I should know the outcome of the appeal within two weeks. When I called bc/bs about my plan they told me that harvoni was on their list of approved drugs but that I need to get it through a specialty pharmacy. That would be no problem. But now the "cadillac" of health insurance has denied the tx ordered by my doctor and I am extremely unhappy about it. They are supposed to pay up but would rather see us die and be done with. I feel like taking some of them with me. I'd like to inject the person who denied my medicine with some of my blood and see how they feel. Sorry for venting. I'm very upset.
2059648 tn?1439770265
Welcome to to to the world of having health insurance.  I have been fortunate to have had health insurance all my life.  What your experiencing isn't unusal.   So don't get frustrated with this.  Health insurance is provided by a company.  Always looking to save money.   Your liver damage is medium and you do have months to get this done.  Come on Carl.  Harvoni is over $100,000.  Of course they what to make sure your serious.  You just got insurance for the first time.  Wouldn't it be something if they sent you Harvoni and you changed your mind?  You can't just send it back.  It not returnable.  Show them you want Harvoni and appeal till you get what you want.   Again, welcome to the insured world.  : )
4896357 tn?1360674504
Thank you. I'm sorry for venting here. I have a lot on my plate right now. I will see how the appeal goes. If they deny it I will seek help from the drug company and I will sue bc/bs in small claims court for my premiums back since they did not honor their side of our contract. I need to calm down and cool off. Thanks for putting up with me. Hep C kills 56,000 people every year.....
1 Comments
Listen to don't worry be happy.He is 100% correct.Its automatic that your ins company will refuse the 1st and probably the 2nd time.They will pay for the harvoni.put in a third appeal and while your doing that your 2 denials are whats needed to get assistance from the drug companies patient assistance program.Do both
2059648 tn?1439770265
Carl let me give you an example of how health insurance works.   It's much like what your experiencing.
_______________

My insurance company covers this high cost medication for knee injections.
So great!  I go to the doctor and get a prescription for this medication my insurance stated up front was covered.   Take it to the my CVS pharmacy.
The pharmacy notes its a specialty item and contacts the CVS Caremark.  The prescription isn't covered.

The reason being is its not a prescription its a "procedure" that involves a prescription that can only be administered by a doctor.   So the doctor has to get the prescription.  But the doctor doesn't contract with CVS Caremark and so has to purchase at a much higher price costing the doctor money to provide the prescription.  So as a result even tho the drug is covered by my insurance.....it's not obtainable.   Because the doctor doesn't see any reason to submit for approval because it's not worth his time.   There's nothing in it for the doctor.  

I have now gone to a different doctor willing to submit to my insurance company to obtain the prescription.   It's been a process of a few months.   Today is the last day to see if my insurance company approves or denies this prescription ordered by my doctor.  Then if denied there will be an appeal bases on medical nessessity claim written by the doctor.    

It's the process that your not familiar with.   Heath Insurance is a very complicated experience for the patient.  And yes it confusing and can **** you off.   I do understand.  But just go thru the process to the fullest.





Avatar universal
Hi Carl,

I got denied also the first time.  My Hepa appealed it and now BCBS wants drug tests done before they approve.  One lab is for Alcohol Metabolism and the other is Drug Screen & Marijuana.  So now BCBS is making sure no one is drinking or taking drugs while on this expensive treatment.  I will get the labs done tomorrow and hopefully I can get approved by next week.  They are doing everything they can think of not approve this.  Good luck!

jules
276146 tn?1453924624
Hi Jules, sounds just like me, except my insurance in United Healthcare.  Got denied, its being appealed and my insurance wants a urine sample to test for drugs.  Did that this morning....You're right...the insurance companies are dragging this out and doing everything in their power not to approve....
2059648 tn?1439770265
Just a few years ago many professionals knew minimal about Hepatitis C
and treatment.  That practice is changing at an amazing rate.  There are college accredited courses on Hepatitis C and treatment.  There are now
vast amounts of current information being presented to the medical profession, work settings and the general public.  

This Hepatitis C treatments are extremely expense.  One of the modules in the training of hepatitis C treatment is the "presents of alcohol and drug use"on treatment.  The referenced importance of the willingness to not drink or do drugs is also an important fact in determining the success of treatment.

Insurance companies want you to succeed if you go through the treatment.
I believe in the long run it can save money if you are cured.  I remember the process for getting approved for Hepatitis C treatment was a process.
I also,  believe that if a better screening process was in place for Incivek...
many would have been denied treatment.  

I'm not a doctor or a person who cares if you drink or do drugs.  That is your own business.   But I would have a had time honestly supporting someone who refused or continued to drink and do drugs while treating there hepatitis C.  There could be problems with you not remembering to
take this very expense drugs.  This could harm your chances of obtaining
SVR.   After reading the many drugs that have an interaction with Harvoni
it would be risky to even think of taking drugs.  You doctor wants to know
exactly what your doing to increase your success.   That you are motivated to treat your Hepatitis C by refraining to do these things.

Many drugs say right on the bottle to not drink alcohol while taking this medication.  This could cause the medication to not work as well or cause
an interaction.  So, the fact that insurance companies are being extremely
careful with these hep c drugs your doctor is prescribing isn't surprising.

I get great pleasure in saying test me for anything.  My health is most important to me.   The proof is in my blood work.





  

Avatar universal
The insurance companies are asking for tighter compliance due to the expense of the medications.  That is a no brainet but dont place addiction with compliance.  Addicts can be very complient.  Just remember you never who you are talking to..especially online
2059648 tn?1439770265
It's not personal.  It's simply what I have read about requirements in hepatitis c training modules for professionals concerning  alcohol and drugs use.
Does seem to be considered in the process.
Avatar universal
same with me but today I got a call from the specialty pharmacy they said my preauth cleared for the Sovaldi but theres a 20,000 dollar copay. I laughed in there face. I have medical Insurance through my company they deduct a lot of money from my check and that's what they can offer, Its BS and I too am pissed off. Im appealing it again and hopefully Gilead will give me assistance.
1815939 tn?1377995399
It is a misconception that addicts and alcoholics are not/can not be compliant with their medications. That is an assumption (based on bias) among some medical professionals, but it is a false assumption.

Statistically, alcoholics and addicts are just as compliant as non-addicts/non-alcoholics. In addition, the SVR rates for addicts/alcoholics and non-addicts/non-alcoholics were similar.

This topic has been discussed many times on this forum. Data backing up the statistics have been posted several times. When I find the data, I will post the links.
2059648 tn?1439770265
This issue is coming up in the latest Hepatitis C treatment.  Insurance companies asking for proof as Jules stated.  

This is off a Checklist for before starting treatment for Hepatitis C.

Drug and/or alcohol use evaluated and addressed so as not to interfere with
therapy.

Otherwise, will your drug or alcohol use interfere with your Hepatitis C
treatment.   I guess by testing you for drugs and alcohol that is part of
the equation to address if it may.
Avatar universal
Insurance company's has and always will ask different questions so to assume something is meant by a certain box to check doesn't seem right. I will support anybody. I could care less whether they have a beer a day or even smoke some pot... The facts speak for themselves. If you don't agree with them then fine.


http://www.hepatitis.va.gov/provider/guidelines/2006HCV-groups.asp


Patients with Ongoing Alcohol Use
in those who completed HCV therapy, SVR was similar in drinkers and nondrinkers . Thus, alcohol users should not be excluded from antiviral therapy but treatment adherence should be stressed



Patients with Ongoing Alcohol Use

Alcohol is an important cofactor in the progression of HCV disease to cirrhosis and HCC (43) . Thus, patients with hepatitis C should limit or abstain from alcohol consumption. Limited data suggest that heavy alcohol consumption of >80 g/day (approximately eight drinks or more per day) reduces HCV treatment response. It is unknown whether consuming less alcohol compromises HCV treatment response (44) . In patients with recent alcohol consumption, there were higher treatment discontinuation rates; however, in those who completed HCV therapy, SVR was similar in drinkers and nondrinkers (45) . Thus, alcohol users should not be excluded from antiviral therapy but treatment adherence should be stressed (9) .



RECOMMENDATIONS IN PATIENTS WITH ONGOING ALCOHOL USE

1. Patients should be encouraged to decrease consumption or to abstain (III).

2. Patients should be referred for behavioral intervention to reduce alcohol use (III).

3. Antiviral therapy should be offered to patients regardless of prior alcohol use who otherwise meet criteria for therapy (II-2).

4. Alcohol consumption should be discouraged during antiviral treatment, because alcohol reduces adherence and treatment response (III).
2059648 tn?1439770265
This was brought up by Jules that testing was being done for alcohol and
drugs in connection with insurance and Hepatitis C treatment.  The fact is
that it happening.  They just don't take your word.  Its just a fact.

FYI:  Clinical trials pick the people for the trials to obtain the best results.

I don't have an argument.  These are just facts.
6708370 tn?1471493810
I feel for everyone who has to go through all of this annoying insurance rigamarole but am so pleased that they are allowed to be "pissed off" about it now
747988 tn?1396540478
am very thankful we have the NHS in the UK,it must be terribly stressful for you guys having to fight for treatment.
4896357 tn?1360674504
Thanks for the replies. I shouldn't have taken out my frustrations here. I was led to believe that I would have no problems getting approved with this best of the best insurance that costs me 1,157 per month and has so far covered very little of the bloodwork and denied all major dental work needed. I do not take drugs except prescribed valium. I have not had a drink since New Years Eve 2013 (over a year). Marijuana is prescribed in Michigan and one of the top tier conditions is Hep C. I don't smoke much but I will test positive for it. In Michigan it is a doctor prescribed medication. The appeals process has been started. Can they deny me for smoking medical marijuana?

I know that many people here are having similar insurance problems. That was a big factor in me budgeting enough money to buy the best insurance. Please know that the best insurance does not mean much. They are putting a price on our lives. I don't want to come across as selfish as I know that we are all going through problems getting cured. I was just shocked and very angry to hear that this insurance plan had turned me down when I was told that I would have no problems with them. It's obvious that they hate covering pre-existing conditions and would prefer that I just go away. I do not, and never have, supported the ACA. It is badly flawed as it does nothing to control the costs of drugs and tx like, for example, Canada's health plan does. The only way it got passed was to allow those who voted it into law to exempt themselves.

I will try not to complain anymore. I was out of line. You guys are my support group though and I did come on here to let off some steam. Thanks for the replies, the support, the understanding and for putting up with me. I love you all. I will jump through the hoops and make tx happen. I am going to pick up copies of my blood test results and the fibroscan study today.

Hepcandme, I didn't know if the P word would get past the cuss filter but it did and I am definitely "P"'d off!!

I would be fine with it if this thread just dies now or gets removed by a moderator.

Thanks again. I couldn't make it without this forum.

:)
Avatar universal
BCBS requires me to go through Quest Diagnostics for all of my bloodwork so I looked up the codes for Quest in case anyone is interested.

Alcohol Metabolism #16910


Pain Management, Alcohol Metabolites, with Confirmation, Urine  


Overview


Ordering Info





CPT Code(s)

80101

Includes

Ethyl Glucuronide and Ethyl Sulfate

If Screen is Positive, a confirmation will be performed at an additional charge (CPT code(s): 83789).

Methodology

Mass Spectrometry (MS)

Reference Range(s)

Alcohol Metabolites <500 ng/mL
   Ethyl Glucuronide (EtG) <500 ng/mL
   Ethyl Sulfate (EtS) <100 ng/mL

*******************************************************
Drug Screening & Mari #16484

Pain Management Profile 4 with Confirmation, without medMATCH, Urine


Test Code

16484X

CPT Code(s)

80101 (x9) (HCPCS: G0434), 82570, 83986, 84311

Includes

Creatinine, Oxidant, pH, Amphetamines, Barbiturates, Benzodiazepines, Cocaine Metabolite, Methadone, Opiates, Oxycodone, Phencyclidine, Propoxyphene

Preferred Specimen(s)

30 mL urine

Minimum Volume

7 mL

Alternative Specimen(s)

Urine collected in urine collection container

Transport Container

Clinical drug test transport vial

Transport Temperature

Room Temperature
Refrigerated is also acceptable.

Specimen Stability

Room temperature: 5 days
Refrigerated: 7 days
Frozen: 30 days

Reject Criteria

Preserved samples

Methodology

Screen: Immunoassay (IA) • Confirmation: Mass Spectrometry (MS)

Performing Laboratory

Quest Diagnostics Nichols Chantilly  
14225 Newbrook Drive P.O. Box 10841
Chantilly, VA 20153


Setup Days

Monday - Saturday

Reference Range(s)

Creatinine ≥20.0  mg/dL
Specific Gravity ≥1.003  
pH 4.5-9.0  
Oxidant <200 µg/mL
Amphetamines  <500 ng/mL
   Amphetamine <250 ng/mL
   Methamphetamine <250 ng/mL
Barbiturates <300 ng/mL
   Amobarbital <100 ng/mL
   Butalbital <100 ng/mL
   Pentobarbital <100 ng/mL
   Phenobarbital <100 ng/mL
   Secobarbital <100 ng/mL
Benzodiazepines <100  ng/mL
   Alphahydroxyalprazolam <50 ng/mL
   Alphahydroxytriazolam <50 ng/mL
   Lorazepam <50 ng/mL
   Midazolam <50 ng/mL
   Nordiazepam <50 ng/mL
   Oxazepam <50 ng/mL
   Temazepam <50 ng/mL
Cocaine Metabolite <150 ng/mL
   Benzoylecgonine <100 ng/mL
Methadone <150 ng/mL
   EDDP <100 ng/mL
   Methadone <100 ng/mL
Opiates <100 ng/mL
   Codeine <50 ng/mL
   Morphine <50 ng/mL
   Hydrocodone <50 ng/mL
   Hydromorphone <50 ng/mL
Oxycodone <100 ng/mL
   Oxycodone <50 ng/mL
   Oxymorphone <50 ng/mL
Phencyclidine <25 ng/mL
   Phencyclidine <25 ng/mL
Propoxyphene <300 ng/mL
   Norpropoxyphene <200 ng/mL


LOINC®' Code(s)

The Result and LOINC information listed below should not be used for electronic interface maintenance with Quest Diagnostics. Please contact the Quest Diagnostics Connectivity Help Desk for more information at 800-697-9302.

NOTE: The codes listed in the table below are not orderable Test Codes.


Result
Code

Result Name

LOINC Code

Component Name



82000000

Amphetamines

3349-8

Amphetamines


82000010

Amphetamine

19346-6

Amphetamine


82000020

Methamphetamine

3780-4

Methamphetamine


82000030

Barbiturates

3377-9

Barbiturates


82000040

Amobarbital

11230-0

Amobarbital


82000050

Butalbital

11071-8

Butalbital


82000060

Pentobarbital

3926-3

Pentobarbital


82000070

Phenobarbital

3950-3

Phenobarbital


82000080

Secobarbital

19695-6

Secobarbital


82000090

Benzodiazepines

3390-2

Benzodiazepines


82000100

Nordiazepam

15372-6

Nordiazepam


82000110

Oxazepam

3887-7

Oxazepam


82000120

Lorazepam

3725-9

Lorazepam


82000130

Alphahydroxyalprazolam

19328-4

Alpha hydroxyalprazolam


82000140

Midazolam

19588-3

Midazolam


82000150

Alphahydroxytriazolam

60677-2

Alpha hydroxytriazolam


82000158

Temazepam

12382-8

Temazepam


82000180

Cocaine Metabolite

3393-6

Benzoylecgonine


82000190

Benzoylecgonine

3394-4

Benzoylecgonine


82000200

Methadone

3773-9

Methadone


82000210

EDDP

50542-0

2-Ethylidene-1,5-Dimethyl-3,3-Diphenylpyrrolidine


82000220

Methadone

3774-7

Methadone


82000230

Opiates

3879-4

Opiates


82000240

Codeine

3508-9

Codeine


82000250

Morphine

3831-5

Morphine


82000260

Hydrocodone

3681-4

Hydrocodone


82000270

Hydromorphone

9835-0

Hydromorphone


82000280

Oxycodone

10998-3

Oxycodone


82000290

Oxycodone

11246-6

Oxycodone


82000300

Oxymorphone

19648-5

Oxymorphone


82000310

Phencyclidine

3936-2

Phencyclidine


82000320

Phencyclidine

3937-0

Phencyclidine


82000330

Propoxyphene

19141-1

Propoxyphene


82000340

Norpropoxyphene

19635-2

Norpropoxyphene


84002710

Specific Gravity

2965-2

Specific gravity


84002720

pH

2756-5

pH


84002730

Creatinine

2161-8

Creatinine


84002740

Oxidant

58714-7

Oxidants
**********************************************

Carl I would think since you have a script for Marijane you would be ok.  I don't know maybe ask your Dr.

jules
4896357 tn?1360674504
Thanks for the good info. I have not been tested for illegal drugs. My blood tests are pretty good with everything in range except HCT very slightly high and ALT also slightly high at 55 and GGTP up to 105. Again, my fibroscan shows no fibrosis or cirrhosis at 4.1. The bad news is that my VL has shot up to over 8 million. Appeal process has begun.  
Avatar universal
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