Harvoni is one of just several medications that can cure Hepatitis C. In fact, of patients are cured within 12 weeks of beginning treatment. Despite the drug’s effectiveness, insurance companies requests for coverage. If you’re one of the thousands of people who have been denied Harvoni, here are 3 reasons why you may have been denied.
WHY INSURANCE COMPANIES ARE DENYING HARVONI
For a full course of the medication, Harvoni costs per person. As a result, insurance companies are going to great lengths to limit their coverage for the drug and protect their financial self-interest. Below are several reasons that your insurance company may deny your request for Harvoni.
1) You’re not sick enough. One way insurance companies are limiting their Harvoni coverage is by saying the treatment is not yet “medically necessary” for certain patients. This is because insurance companies use to make their coverage decisions. If your treatment is not considered “medically necessary” under these guidelines, your insurance company can deny you coverage. Harvoni is supported as medically necessary treatment under most clinical policy guidelines. However, these guidelines also recommend “” of Harvoni for patients with advanced liver disease. As a result, many insurance companies are using this language to prioritize Harvoni for patients with Stage 3 or Stage 4 liver disease and deny coverage for patients that haven’t yet developed that level of liver damage.
2) Your drug test came back positive. Some health insurance companies require you to prove your before authorizing Harvoni treatment. If your drug test comes back positive, your company can deny your coverage.
WHAT TO DO IF YOUR REQUEST FOR HARVONI TREATMENT WAS DENIED
Even if your request for Harvoni has been denied, you may still be able to receive the treatment you need. In 2014, of California patients received approval for Harvoni after they appealed to California’s Department of Managed Health Care to reverse their insurance company’s denial. In the event that you have been denied Harvoni, consider taking the following actions:
1) Get a doctor that will advance your case. Because insurance companies can deny your request for Harvoni on the basis that it is not medically necessary treatment, make sure your doctor is prepared to use his or her medical expertise to of Harvoni and to challenge to your insurance agency’s interpretation of its clinical policy guidelines on your behalf.
2) Appeal the denial through your insurance company. Contact your insurance company to their decision to deny your coverage. Make sure to work with your doctor beforehand to acquire a statement of medical necessity as well as any other required medical records and supporting documentation.
5) File a lawsuit. Several have already been filed against insurance companies on the basis that they failed to provide medically necessary treatment. These have been in forcing insurance company’s to loosen several restrictions for authorizing Harvoni treatment.
If your request for Harvoni was denied by your insurance company, contact ClaimCounsel to see if we can help get the benefits you were promised.