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Author Topic: egrifta is rejected by Medicaid  (Read 4690 times)

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Offline whally

  • Member
  • Posts: 5
egrifta is rejected by Medicaid
« on: October 31, 2011, 01:49:19 PM »
I was on Egrifta, enjoying the benefits and hope the drug was giving when suddenly Medicaid said they would not cover it as it is cosmetic.  My doc went the rounds to no avail.
So, We tried the assistance route offered by the Axis foundation and they approved me but since I am on Medicaid I can't receive it because of some new law against kickbacks. ?  I really do not understand this at all.
I was really doing good on it.  I have upper lobe emphysema and the build of belly fat decreases my breathing increasingly each day.  Plus the extra 40 lbs doesn't help.

I was becoming hopeful of having a normal life and maybe even working again

Does anyone know if you can appeal with Medicaid and what would be the best route?  I've studied all over the net and this is such an unusual case that there is really no prior experiences.  I feel trapped!

Thanks
gerry

Offline mewithu

  • Member
  • Posts: 160
  • mewithu
Re: egrifta is rejected by Medicaid
« Reply #1 on: March 12, 2012, 11:13:09 AM »
 I wouldn't mess with the Medicaid over just a cosmetic drug. There are drugs you can get for your face that medicare or the company pays for and then you pay the Dr to put it in your face where you need it.
1997 is when I found out, being deathly ill. I had to go to the hospital due to extreme headache and fever. I fell coma like,  two months later weighing 95 pounds and in extreme pain and awoke to knowledge of Pancreatis, Cryptococcal Meningitis, Thrush,Severe Diarea,  Wasting, PCP pneumonia. No eating, only through tpn. Very sick, I was lucky I had good insurance with the company I worked for. I was in the hospital for three months that time. 
(2010 Now doing OK cd4=210  VL= < 75)
I have become resistant to many nukes and non nukes, Now on Reyataz, , Combivir. Working well for me not too many side effects.  I have the wasting syndrome, Fatigue  . Hard to deal with but believe it or not I have been through worse. Three Pulmonary Embolism's in my life. 2012 520 t's <20 V load

Offline denb45

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  • Posts: 5,051
  • "1987 Classic Old School POZ+"
Re: egrifta is rejected by Medicaid
« Reply #2 on: March 12, 2012, 11:55:07 AM »
I was on Egrifta, enjoying the benefits and hope the drug was giving when suddenly Medicaid said they would not cover it as it is cosmetic.  My doc went the rounds to no avail.


Well,  I'm not on Medicaid (don't qualify for it) and also I just found out that my BCBS doesn't cover Egrifta
and it's not even on the formulary HIV/AIDS list in my State for ADAP, and i have funny feeling it never will be  :-[

So your not alone, so don't feel too bad about it, I know it must be worse for you as you did get a change to at least use it for a while  :(

I do know that cosmetic type drugs are somewhat of a very hard-sell as for as some health Ins. companies look at it, so for me it was a long-shot and worth a try, but someone else (or the powers that be) won't let me even try Egrifta.....Oh well such as life I guess  :(
"it's so nice to be insane, cause no-one ask you to explain" Helen Reddy cc 1974

Offline pozniceguy

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  • Posts: 1,169
  • Niceguy Dallas
Re: egrifta is rejected by Medicaid
« Reply #3 on: March 14, 2012, 01:53:19 PM »
Egrifta is  not  sold or reccommened as a "cosmetic"   .... it is  sold and used to  reduce internal accumulation of fat  around the  organs like heart/intestines and stomach... Medicare  pays and the Dr  ( clinic )  I use  fully supports the use for  such  purposes....    the  cost is the  reason some providers (  like  medicaid)  have  decided to  not supply it....it is  expensive  and their  funds are limited  so they keep it off the  formulary   they may say it is a  cosmetic  but that is a local "feel good"  determination...factually, by  extensive  testing it  is for internal fat accumulation
remember the good times...honor the past but don't live there
Le stelle la notte sono grandie luminose, nel cuore profondo del Texas

Offline denb45

  • Member
  • Posts: 5,051
  • "1987 Classic Old School POZ+"
Re: egrifta is rejected by Medicaid
« Reply #4 on: March 14, 2012, 02:05:19 PM »
Yeah , it's the COST, my BCBS doesn't cover it, so I cannot get it anywhere else, and I cannot use medicare Part d to get it, I had to have it deactivated when I signed over my Medicare to them 2 1/2 yrs ago, so I'm kinda shit-outta-luck  :-[
"it's so nice to be insane, cause no-one ask you to explain" Helen Reddy cc 1974

Offline aztecan

  • Member
  • Posts: 5,358
  • 28 years positive, 56 years a pain in the butt
Re: egrifta is rejected by Medicaid
« Reply #5 on: March 15, 2012, 12:55:49 AM »
Medicaid is a publicly funded program. That means that what money is available (and there is never enough), must be spread out to benefit the most people. Egrifta is not covered because it only benefits a few and its cost is prohibitive.

I am somewhat surprised Medicare pays for it, but I guess that also would depend on which Part D plan you have and whether or not you have a medigap policy

I have private insurance from my employer, but still cannot get Egrifta. Moreover, if it did cover it, it would most likely fall under the Tier 4 formulary, now used by many if not most insurers, that would require me to pay a percentage of the cost of the medication, not just a simple co-pay. In my case, that would be 20 percent. So, if Egrifta costs $1,000 a month, my portion would be $200 a month. I believe Egrifta goes for more than $1,000 a month, but that was an easy example.

The bottom line for me is I already pay nearly $300 a month in co-pays each month just for the meds I take now. Adding $200 or more to that would be untenable.

Mind you, the drug is meant only for visceral adipose tissue, that fat which forms around the internal organs and is most likely a result of ARV therapy, especially the old meds.

This came from an article on The Body,

Quote
This drug was specifically studied in people with excess abdominal fat. What's the extent of knowledge as far as how well or not well it will work for any other form of fat gain throughout the body?

Oh, there's been a lot of questions about people with different types of fat accumulation. Normal people that have, for example, subcutaneous fat as opposed to visceral fat -- obviously this drug has not been studied for that situation. But suffice it to say that the medication Egrifta, it showed a very specifically targeted effect on visceral fat with reductions. It didn't show any specific changes with limb fat that was significant in any way, nor in terms of subcutaneous fat.

So, anyone hoping this drug would rid them of their beer belly or love handles is out of luck.

Moreover, also from the same article:

Quote
You were referring to buffalo hump a little bit before. Is there any indication that it could help with that kind of complication?

In the study, and it hasn't been studied significantly, there have been some reports of one or two patients that have had fat accumulation such as buffalo hump that did get benefit when they were on the Egrifta. But again, this wasn't studied and it's hard to make any big conclusions from that.

That article was from 2010, so it is two years old. I haven't seen anything since then discussing the buffalo hump.

In my case, that is just as troubling as the gut, although probably less life threatening.

Anyway, it's a moot point. I can't afford it.

HUGS,

Mark

"May your life preach more loudly than your lips."
~ William Ellery Channing (Unitarian Minister)

Offline pozniceguy

  • Member
  • Posts: 1,169
  • Niceguy Dallas
Re: egrifta is rejected by Medicaid
« Reply #6 on: March 18, 2012, 03:21:10 PM »
Mark , you are  correct  Egrifta  cost a lot more than that   the  bill sent to the provider pharmacy is  $2005.00   for a 30  day  "kit"  which  includes all the  stuff  you need  ,needles, alcohol wipes,and  mixing  solution ....  expensive  ...yes    , very...but witha  family history of  Heart issues a needed precaution to minimize the  fat  accumulation on visceral and other organs.....   My  Dr  has to  request  re-authorization every  6  months


Nick
remember the good times...honor the past but don't live there
Le stelle la notte sono grandie luminose, nel cuore profondo del Texas

Offline aztecan

  • Member
  • Posts: 5,358
  • 28 years positive, 56 years a pain in the butt
Re: egrifta is rejected by Medicaid
« Reply #7 on: March 18, 2012, 10:02:19 PM »
Mark , you are  correct  Egrifta  cost a lot more than that   the  bill sent to the provider pharmacy is  $2005.00   for a 30  day  "kit"  which  includes all the  stuff  you need  ,needles, alcohol wipes,and  mixing  solution ....  expensive  ...yes    , very...but witha  family history of  Heart issues a needed precaution to minimize the  fat  accumulation on visceral and other organs.....   My  Dr  has to  request  re-authorization every  6  months

Nick

Yikes! It is more than I thought. That would make my monthly copay $401!  :o

There is no way I could afford it.

The prior authorization thing is another issue. Right now, the doctor I see spends an inordinate amount of time wading through endless mechanized telephone systems trying to get prior authorizations for many meds, some the people have been on for years, but suddenly, the insurance company is balking.

I feel badly for Whally, since he was already seeing benefit from Egrifta. I know the state formulary, which designates which med ADAP will pay for, and which, in turn, dictates which meds are covered by other programs, doesn't even list it.

It is just too damned expensive. Even Atripla, at about $2,000 a month, is less costly.

I wish there were another alternative for Whally, and even, maybe, myself.

HUGS,

Mark
« Last Edit: March 18, 2012, 10:06:06 PM by aztecan »
"May your life preach more loudly than your lips."
~ William Ellery Channing (Unitarian Minister)

Offline pozniceguy

  • Member
  • Posts: 1,169
  • Niceguy Dallas
Re: egrifta is rejected by Medicaid
« Reply #8 on: March 19, 2012, 12:22:50 AM »
Mark  , I  dont know  who  writes  the rule  for  determining the  Medicaid Formulary list, but for  Medicare  and most other Government programs   "cost" is  not  supposed to be considered as one of the primary determinations.....  if it  were  then almost all the latest meds available for  treating cancer would be in deep shit...most of  which  cost more per week than the  Egrifta  does for a month......when the  Serostim was  in wider  use it was $10,000  a month  without the  needed  "kit of supplies"..     
 i have  close  relatives  who are being treated  for  cancer  (  weekly sessions at the  clinic) and have seen the  "invoices"  for their  medication.....

Nick
remember the good times...honor the past but don't live there
Le stelle la notte sono grandie luminose, nel cuore profondo del Texas

Offline aztecan

  • Member
  • Posts: 5,358
  • 28 years positive, 56 years a pain in the butt
Re: egrifta is rejected by Medicaid
« Reply #9 on: March 19, 2012, 10:07:38 PM »
I think the difference is the cancer chemo treatments are supposedly temporary, while something like Egrifta is lifetime maintenance.

It is unfortunate, but government programs do indeed look at costs before including them on formularies.

Our state formulary has all the HIV meds on it, but some, like Fuzeon, must have a prior authorization.

Likewise, Fluconozole, to treat thrush and other fungal problems, is limited to a single month without prior authorization.

I work with the Indian Health Service too. It is a federal program, so you might think they have more discretion.

But, alas, they sometimes must pinch pennies too. I remember they prescribed Sustiva/Truvada rather than Atripla the first few years the latter was out because it was cheaper to prescribe them seperately.

Anyway, it all boils down to money, or lack thereof.

HUGS,

Mark
"May your life preach more loudly than your lips."
~ William Ellery Channing (Unitarian Minister)

 


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