lost what to do _Hep C Ribo , Sovaldi etc

[Jensrdy]

my husband was diagnosed with Hep C , genotype 1 last year. He has Medicaid and they approved his Ribo and Sovaldi  and he started taking treatment from April of this year 2014. He then chose EHealth  as his provider and they denied his medication . The new drugs have worked fine with very little side effects and have started to attack the virus. Now  EH  wants  the doctor to write a letter of medical necessity but because he never took the interferon what can he say.... Should I appeal ? should I change plans ? Help? In unchartered waters and don't know what I should do? Help        

[patra_]

Just a side note:n you said the new Meds are working fine with very little side effects - that should be a helpful argument in itself.  I feel sure the dr can show the results of the blood tests to help support the appeal.  Good luck to you and your husband in this.  Pat

[nan535]

"He still has his medicaid, he just chose a plan and they are the ones refusing the specialty pharmacy program because he hasn't met the " appropriate clinical criteria"

According to the hcv guidelines, your husband's treatment is appropriate under certain conditions. You husband's doctor decided on this treatment for a reason. My guess is its because of one of the reasons below.  He should be fighting this battle with the new insurance company as Hector has said.

http://www.hcvguidelines.org/fullreport  page 33

Alternative regimens for treatment-naive patients with HCV genotype 1 who are not eligible to receive IFN.
Daily sofosbuvir (400 mg) and weight-based RBV (1000 mg [75 kg]) for 24 weeks is an acceptable regimen for IFN-ineligible
IFN ineligible is
defined as one or more of the below:
• Intolerance to IFN
• Autoimmune hepatitis and other autoimmune disorders
• Hypersensitivity to PEG or any of its components
• Decompensated hepatic disease
• Major uncontrolled depressive illness
• A baseline neutrophil count below 1500/?L, a baseline platelet count below 90,000/?L
or baseline hemoglobin below 10 g/dL
• A history of preexisting cardiac disease persons with HCV genotype 1 infection,regardless of subtype; however, preliminary data suggest that this regimen may be less effective than daily sofosbuvir (400 mg) plus simeprevir (150 mg), particularly among patients with cirrhosis.
Rating:
Class IIb, Level B

I wish you  and your husband the best. Keep up the fight. His very life is at stake.

Nan

[Jensrdy]

He still has his medicaid, he just chose a plan and they are the ones refusing the specialty pharmacy program because he hasn't met the " appropriate clinical criteria" You all have given me some good advice and leads to follow, u as well Nursehepc , I will keep you posted.

[Jensrdy]

I will call the drug companies myself . When my husband was initially diagnosed last year, the doctor wanted him to wait until this year because he was working personally with the drug companies  and these new drugs. When we were denied the doc immediately said he would try to get it from the company itself . I will pursue this as well, going to interferon now is not an option when these meds have been working so well at attacking the problem.

[Jensrdy]

The health plan with EHealth was only from May 1st so he is still within his 60 days to change. I will ask the doctor what is a better plan to change to .....Hector,  you made some valid points and I am getting on them to see what they are doing.You are correct " appealing refusal" is something I am sure they are familiar with , it's what they do. guess I thought my case was unique, you are correct. Thanks for telling me I have to hold their feet to the fire, on it!!...I appreciate it!

[nursehepc]

Hector is right, your Dr. should be handling this and knows what to write (stopping in the middle of treatment is not something anyone wants). Hound your Dr./nurse case manager.

I also think that you should take SimpleMan's advice and call the pharmaceutical companies to see what advice they give you (also because they may help you by either intervening  or providing you with the drugs).

I am sorry for your trouble. I hope things work out for you.

Joanne.

[SimpleMan1959]

Why did he lose his Medicaid and can he get back on it, you tell them this is a life threaten event. Call the company that makes these meds too and tell them your situation.

[Sovaldi13Newbie]

Just as a quick measure that you might not have to do, always remember that you can appeal to the drug co's themselves, I did...and they approved my medication after my initial insurance denial. Then my insurance approved it after my appeal (I hear some people say this happened to them too, they got it on appeal) and of course Gilead, et al said I was approved and go with the insurance. Best of luck to you, what Hector says makes sense!!

[HectorSF]

I don't think you can change the health plan now unless he just changed it and there is an option to change it within the first 30 to 90 days.

His doctor should appeal the denial ASAP. Interferon is not the issue. He needs to continue his treatment. You can't add interferon now and change the treatment while he is treating. Stopping treatment now in the middle of treatment would be a horrible idea.

The doctor's office should be experienced enough to submit the proper information to EH to get approval for the treatment he is on.

This is his doctor's responsibility NOT yours! Your job is to stay on top of the doctor's office so they follow through and get the treatment approved ASAP. Treatment should never be stopped.

Appealing refusal for proper medical treatment for patients is what they do day in and day out. It should not be difficult to do. Make them do their job.

In the future, switching health insurance when dealing with a medical issue needs proper care and attention to be sure the all services will be covered under the new policy.

Good luck!
Hector