Anita Kissinger is an aggressive advocate for her health. When the retired teacher and administrator, who worked for a self-insured school district in Missouri, was diagnosed with hepatitis C in 2014, she had to fight for access to a cure....
...Her doctor prescribed Harvoni, a new drug from Gilead that has the rarest of qualities—the capacity to cure most patients. Then came the bad news: The district’s health insurance plan for prescription drugs, which is managed by MedTrak, a pharmacy benefit management (PBM) firm, turned her down for the drug, which costs $94,500 for a course of treatment.
Kissinger filed an appeal and was refused again. She appealed again and the insurer responded that it would reconsider coverage if a fibroscan indicated there was sufficient damage to her liver. After the scan, the plan turned her down again.
Kissinger retained a lawyer who began communicating with the insurer on her behalf. Eventually she received approval for a course of treatment with Harvoni. She then took her $5,000 copay to the drug’s manufacturer. Gilead paid all but $15. In the end, Kissinger received the benefit of the $94,500 breakthrough drug for $2,015, including legal fees.I gotta say, if I were stuck in that situation, I would be incandescently angry at everyone involved. I don't think Gilead can escape some culpability for causing the situation (i.e. pricing Harvoni at a very high price)*, even if they were ultimately not responsible for a process that requires showing sufficient damage to her liver.
*UPDATE: Dr. Zoidberg makes a good point that I missed about Harvoni's value to the patient. I think that Dr Z. is right in that Harvoni deserves a high price in that it is a cure, and that they have done a bad job of communicating its value. What I was trying to communicate (poorly) is my belief that Gilead set the terms of the debate, and should have known that it would come out badly for them, even though they were the ones who were providing Harvoni.
"Go argue with your insurance company" is not a solution that's going to endear pharma companies to patients.