Update: My doctor and I got a letter from my insurance saying that they rejected Nexavir because there was no National Drug Code number or because the National Drug Code number was not accurate. It was really just a way for the insurance to avoid paying for this medication. Anyway, they rejected it and then they rejected our appeal (i.e. denied the appeal).
So after the appeal was denied, we sent them the court ruling -- the one that was posted in the post just above this one. We asked them to reconsider their denial of the medication, since this FEDERAL judge ruled in favor of the patient (who had been denied the medication for the exact same reason as me).
Well, I just got a letter back the other day saying they are "re-opening" the case and will consider the "new evidence" (the court ruling). They said they'd let me know within 120 days.
120 days?! Yes, they have 120 more days to save money by not giving the patient access to this medication.
But at least they are reconsidering the denial.
Will keep you posted.
Here's a development.
The defendants appealed the case I posted, and the Medicare Appeals Council (MAC) overturned it (i.e., ruled against Part D coverage for Nexavir). But you are not obligated to inform your Part D carrier or any appeal entity of this (let 'em do their own homework), and the plaintiff is asking the MAC for a reconsideration, alleging errors of fact and law.
(It appears the MAC overlooked evidence in the case file that Nexavir is identical to Kutapressin, as the plaintiff argued and the judge agreed. Kutapressin is eligible to be grandfathered into Part D because it was marketed before the 1962 FDA Drug Amendments. Nexavir, being identical, would be eligible too. Let's see what the MAC says.)
Meanwhile, Nexco has decided to discontinue the injectable form of Nexavir (a business decision, not medical), and supplies are dwindling. Nexco is offering a transdermal gel instead (
http://www.eclipseacts.com/nexavir-gel.htm). Whether Nexavir in gel form would be eligible for grandfathering into Part D is a whole other can of worms, as is the fact that currently it appears to be a compounded drug (made up specially for each prescription). It would be a fight.
Another follow-on option is an injectable form of Hepapressin compounded by College Pharmacy in Colorado (800-888-9358). Same idea except using bovine liver and their formula is not thermostable, which means it must be refrigerated and has only a 90-day shelf life. (On the upside, no preservatives, if that's an issue.) My pricing info is about 2 years old--jeez, time flies when you're lying in bed---but I was quoted $33.08 for each 10 mL vial (the only size they do), and the concentration is a little less, about 22 mg of liver derivative per mL (Nexavir is 25.5 mg/mL). Available by prescription only, but they will ship to the patient. And then there's the compounding problem vis-a-vis coverage under Part D.
Don't shoot, I'm just the messenger, but maybe there's something useful here.
