Canadian Insurance Denied my Sovaldi/Galexos Protocol...Need Suggestions.

Hello, I am new to this forum and just joined today. I was diagnosed in 2005 with Hep C and so far have been able to stay away from the treatment of Interferon and Ribavarin because I felt I couldn't deal with the side effects, then brand new drugs came on the market called Solvaldi and Galexos with a much highercure rate and less side effects. I enrolled in a support program and signed the consent forms, then today I heard from my benefits (Manulife) and they have denied the Solvaldi and Galexos. I called them up and asked why they would deny drugs that have been approved by Health Canada, and they said there is nothing they can do, I am at wits end and don't know where to turn for help, does anyone know of support programs or drug benefits carrier that covers these two drugs.

Thank you.

Post Edited By Moderator (MamaLama) : 9/4/2014 9:47:05 PM (GMT-6)

Mama Lama

Thank you for your post, I will go through the old posts to see what other Canadians did to receive treatment.

To give you more insight, I live in Ontario Canada, and my insurer is Manulife Group Plan Member. They said they can not cover the two drugs prescribed by my Doctor because they are off label. I will see my Doctor soon to discuss the next step. I was told he is good at writing letters to the insurer...so I will try that route first and they also said maybe a lawyer is needed. The doctors here are in contact with insurers fighting for their patients to no avail....The problem in Canada is they do not have all the information from all the results of patients being treated in Canada, therefore, in their minds no proof that these drugs actually work in curing the virus...In the US the studies have been completed, Canada is not there yet...hopefully soon they will catch up.

Dorad

Barry, Thanks for the great update. I knew India was in discussion on generics, but do you take this to mean generics will become available at a reasonable fee in the US and Canada? I could not find which 80 countries were involved. Thanks, as always. Big Hugs

(TheStreet) -- Shares of Gilead Sciences (GILD_) fell -4.79% to $101.74 in morning trading Friday after Bloomberg reported the company is close to a deal with generic drugmakers to bring cheaper versions of its $84,000 hepatitis C drug Sovaldi to approximately 80 developing nations, including India, Pakistan and Indonesia.

The licensing deal could go into effect as soon as the middle of this month. It would permit the generic drugmakers to manufacture Sovaldi and another experimental pill that combines Sovaldi with another Gilead hepatitis drug, executive vice president Gregg Alton told Bloomberg.

Gilead intends to sell Sovaldi directly in certain lower income countries, including India, at $900 for 12 weeks of therapy. Sovaldi sells in the U.S. for the controversial price of $1,000 apiece, or $84,000 for 12 weeks. Patients who take Sovaldi stay on it for either 12 weeks or 24 weeks.

your stage 2 fibroscan is the reason you were denied sov/galexos. but it is good news for you. you can wait for these new txs

This may help, possibly? There is a link at the bottom which will take you to the full report. Big Hugs


When and in Whom to Initiate HCV Therapy Table 1. Settings of Liver-Related Complications and Extrahepatic Disease in Which HCV Treatment is Most Likely to Provide the Most Immediate and Impactful Benefits


Highest Priority for Treatment Owing to Highest Risk for Severe Complications


Advanced fibrosis (Metavir F3) or compensated cirrhosis (Metavir F4)

Rating: Class I, Level A

Organ transplant

Rating: Class I, Level B

Type 2 or 3 essential mixed cryoglobulinemia with end-organ manifestations (eg, vasculitis)

Rating: Class I, Level B

Proteinuria, nephrotic syndrome, or membranoproliferative glomerulonephritis

Rating: Class IIa, Level B


High Priority for Treatment Owing to High Risk for Complications


Fibrosis (Metavir F2)

Rating: Class I, level B

HIV-1 coinfection

Rating: Class I, Level B

HBV coinfection

Rating: Class IIa, Level C

Other coexistent liver disease (eg, NASH)

Rating: Class IIa, Level C

Debilitating fatigue

Rating: Class IIa, Level B

Type 2 Diabetes mellitus (insulin resistant)

Rating: Class IIa, Level B

Porphyria cutanea tarda

Rating: Class IIb, Level C


Ratings refer to the strength and level of evidence with regard to benefits of treatment in these settings.





When and in Whom to Initiate HCV Therapy Table 2. Persons Whose Risk of HCV Transmission is High and in Whom HCV Treatment May Yield Transmission Reduction Benefits


High HCV Transmission Risk*


MSM with high-risk sexual practices

Active injection drug users

Incarcerated persons

Persons on long-term hemodialysis

Rating: Class IIa, Level C

www.hcvguidelines.org/full-report/when-and-whom-initiate-hcv-therapy

Hi Dora, You should know that the decision to get a drug approved individually or in combination lays with the manufacturer (not Health Canada, who already approved the drugs individually), and the choice of prescription and choice of therapy falls under the "practice of medicine" in Ontario. Thus, it ought to be YOUR doctor at this point (not your insurance company) who decides what therapy is best suited for you and your current medical condition. Check out this website:

www.fsco.gov.on.ca/en/insurance/complaints/Pages/default.aspx.
The Financial Services Commission of Ontario (FSCO) is responsible for licensing insurance companies in Ontario.

Find out the name of the independent ombudsman for your Insurance company (if not listed, ask them who it is by writing to [email protected]), request a letter from that ombudsman (or complaint officer) stating your insurance company final position so that you can appeal their decision to FSCO along with a letter from your doctor (if he is willing to help... but you can still do it without it!) and don't take no for an answer!!!! EVER... when it comes to fighting for your life.

Monik.

If you have further questions you can write to me...Good luck!

__________________________________

Monik: I have updated your post to make the link "hot" so that members can click on it easily.

And, I have removed your contact information from the text of your message. If you want members to reach you our methodology is to say something like: "If you want to reach me for more information, my email address is in my profile."

To change your profile to have an email posted, click on the My Profile tab just above the posts.

I'm sorry to be a stickler but in the Rules for this forum, the no contact information is Rule #7:
https://www.healingwell.com/community/default.aspx?f=46&m=106997

7. Do not post offline personal contact information (ie. your home address, phone numbers etc.) and do not ask for personal information from others. This is to protect your security and identity.

Mama Lama

Post Edited (Myhusbandhelp) : 11/6/2014 8:59:46 PM (GMT-7)

I agree Dora. I think insurance companies routinely deny claims that they know they shouldn't and give us bogus reasons for rejecting it as if "it is out of their hands" or they are "just following some kind of objective rules"...NOT SO. When you are willing to keep the fight you will get coverage, but you will only get taken seriously when you go beyond them to those who regulate and oversee insurance compliance. I went through what you are going through and when I accidentally came across your post, I decided to become a member to share with you what I learned in the hopes that it will help you as well... I know its upsetting and frustrating, but also highly rewarding when you learn how to fight back and get results!!!

Best,

Monik.

My husband was quite fatigue for years and used to sleep until 12 pm (he has stage 3). I found that eating organic food (not cheap but helpful), has made a big difference. We also bought a serious juicer about 7 months ago and every morning juice: 3 carrots, two beets, an orange, two apples, 2 leafs of kale, some spinach, a piece of red or white cabbage (the greens and beets aren't always organic) and a piece of Ginger. He's got a lot of energy now and gets up before 10 am despite working until late at night! I got one cold in 7 months (used to be a very frequent thing) and now have energy to keep up :)... Before that, we used to take supplements but that wasn't helping nearly as much, I actually think it was a waist of money, many vitamins have little potency and you lose a lot in your urine, but the effects of the juice are quite noticeable! We are not big on exercising but walk more than drive.

I hope you feel better soon,

Monik.

Post Edited (Myhusbandhelp) : 11/6/2014 8:46:20 PM (GMT-7)

No problem, let me know when you start feeling better :D

Monik.

PS: If you are trying out organic you'll get the most benefits from the dairy and meats if you are currently eating non organic dairy and meat that is! Banana and Tomatoes used to give me skin rash until I started buying them organic!!! I also reduce fats and wheat whenever possible by using substitutes such as: avocado chocolate moose (sounds gross, but it tastes really good and NO whipping cream!), agave and brown sugars instead of white sugar, almond flour or white(ish) spelt flour for my cakes (My hubby has a sweet tooth), kamut pasta (don't care for spelt pasta and lentil pasta is disgusting!) and I try to replace heavy creams for evaporated milk... it works most of the time. The less fat and processed foods in you diet, the less stress on your liver and the more energy you'll have ;)

Best,

Monik.

Hi Dorad, I am so sorry to hear about what you are going through with the insurance. I have been there and many times felt like giving up...but that was never really an option.

Let's see if I can put that awful experience to good use and help you:

First, you need to clearly identify your insurance company: there is Sun Life Assurance Company of Canada AND Sun Life Insurance (Canada) Limited.
Then, Write or e-mail to the complaint officer of your respective insurance company (contact information for both of then is bellow). CC this e-mail or forwards the letter to the contact person from the insurance who denied your claim.
Consider presenting here every supporting argument you may have for your claim, for example:
A) Voice how your quality of life is currently affected (state only the facts).
B) According to Health Canada, prescription and drug therapies fall under the jurisdiction of the "practice of medicine", thus it follows that it should be your doctor and not insurance company who decides on the the timing of therapy and the appropriate treatment for your current medical condition.
C) Give a statement from your doctor recommending the denied prescribed therapy for you.

Finally, state that you intend to appeal their decision to The Financial Services Commission of Ontario (FSCO), but in order to do so, you need a letter from them stating their final position.

Sun Life Assurance Company of Canada
Complaint Officer Mike D. Clark
Company Address 150 King Street West, Suite 1400
City, Province, Postal Toronto, Ontario, M5H 1J9
Country Canada
Telephone 416-408-8954
Toll Free 1-800-786-5433 X332-8954
Fax 416-595-1431
E-Mail [email protected]

_____________________________________________

Sun Life Insurance (Canada) Limited
Complaint Officer Mike D. Clark
Company Address 225 King Street West, 7th Floor
City, Province, Postal Toronto, Ontario, M5V 3C5
Country Canada
Telephone 416-408-8954
Toll Free 1-800-786-5433 X332-8954
Fax 416-595-1431
E-Mail [email protected]


Remember to keep all written exchanges in chronological order (you will need them). Once you get the letter with their final position, you can appeal to the independent ombuds service (the final position letter should specify who that person is). Hopefully it won't get to that. In any event, be ready to fight all the way to the bitter end...It's so worth it!!!

I hope this helps,

Myhusbandhelp.

PS: So happy you are juicing. Our religious morning juice has really increased our energy and thus our quality of life... I hear its also very good as a cancer prevention therapy ;D

Post Edited (Myhusbandhelp) : 12/9/2014 10:03:43 PM (GMT-7)