Harvoni is one of just several medications that can cure Hepatitis C. In fact, ninety-nine percent of patients are cured within 12 weeks of beginning treatment. Despite the drug’s effectiveness, insurance companies often deny 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 $95,000 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 clinical policy guidelines 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 “urgent initiation” 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 sobriety before authorizing Harvoni treatment. If your drug test comes back positive, your company can deny your coverage.

3) You didn’t get your prescription from a liver specialist. Your request for Harvoni can also be denied if your insurance company requires you to receive your prescription from a liver specialist.

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, 78 percent 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 argue for the necessity 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 appeal 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.

3) Request an independent review or file a complaint. If your coverage was denied, you can file a complaint or request an independent medical review (IMR) through the California Department of Managed Health Care.

4) Keep trying. Even if your appeal was denied once, appeal again! Some patients finally received coverage for Harvoni after appealing their insurance company’s decisions three or four times.

5) File a lawsuit. Several lawsuits have already been filed against insurance companies on the basis that they failed to provide medically necessary treatment. These have been successful in forcing insurance company’s to loosen several restrictions for authorizing Harvoni treatment.