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Esbriet – Insurance approval
My pulmonologist prescribed esbriet in October, 2021. I have not been able to get an approval for this drug to be filled. Has anyone experienced this. Can you give me some pointers on how I can get this prescription approved?
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25 Replies
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I have a similar issue with my insurance (TRICARE for LIFE as retired military). They use Express-Scripts for all drug transactions and I have to get a form filled out by my pulmonologist and sent into them to get the prescription approved. The approval lasts for a year and I have to go through the whole approval process again. While this may not be quite the same situation as yours I would recommend looking at your insurance company’s formulary for Esbriet and seeing if there is any information there about pre-approval and if not contact them directly or check with the pharmacy to determine what they need to get approval. They just want to make sure you really need it because it is expensive.
Hope that helps.
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I was prescribed Esbriet in September and it took until December to get approved. I believe two factors caused the problem. I wanted Ofev because of less pills and 2X per day instead of 3X per day taking pills. My carrier preferred Esbriet as the starting drug for whatever reason. Second was the problem understanding the requirements of the insurance provider. My doctors nurse was pursuing the prescription thru Walgreens (my drug store of choice) or Tricare (Military retiree). My carrier (United Healthcare) deals with CVS Specialty Pharmacy only so it took several weeks to get to this understanding. Once these two issues were understood and resolved, the approval was fairly swift.
I happen to have good insurance but still lacked 100% no cost. Healthwell Foundation grant that covered the shortfall. Pulmonary Fibrosis is one of their covered diseases.
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I’m fairly certain Esbriet is Medicare approved, and some insurance companies have a policy that they’ll approve what Medicare approves. I’d certainly use that as an argument.
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When my Medicare Part D Insurance did not cover Esbriet, my pulmonologist’s pharmacy (at Cedar’s Sinai in Los Angeles) got me in touch with Genentech, the manufacturer, and I have been getting the medication for FREE for the last year and a half or so. Good luck! See below:
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Genentech Patient Resource Center
Our center dedicated to getting patients and caregivers to the right resources.
Call us at (877) 436-3683 or (877) GENENTECH, Monday-Friday, 6am-5pm PT.Genentech Access Solutions
This service offers coverage support, patient assistance, and other useful information.Genentech Patient Foundation
Provides free medicine to patients without insurance coverage or who can’t pay for their Genentech medicine.RESOURCES
Esbriet.com
Provides additional resources and information.-
Thank you for your feedback! I will research with Genentech.
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If for some reason that doesn’t work try Healthwell.com. It has been three years since they helped me with Esbriet so things may have changed. They paid everything that Medicare didn’t. My net cost was zero.
Healthwell is a non-profit.
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Brenda Colvin. I read an article saying Esbriet and Ofev are not cost effective in the U.S. is that true or do most of you live out of the states. I know it’s expensive but didn’t we wouldn’t have access to it here. I live in Florida. Not on medication yet but want to know options when time comes.
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Hi Brenda, I live in the states and I’m having a hard time getting the prescription filled. My doctor has now changed my medication to Ofev. I guess he thinks they might fill one over the other. Even though Ofev is supposed to be cheaper it’s still expensive so we’ll see how I make out.
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Hi all –
Not sure but think both Esbriet and OFEV require prior authorizations before patients can get either of these medications. I live in the US. I have been on OFEV for 2 1/2 years and I have a prior authorization that is good through the end of 2022. I assume this is something your doctor fills out to show that you medically “qualify” for these drugs. Both these drugs are very similar in costs and co-pays are very high. I am on Medicare but was not when I began taking this OFEV and the co-pays were very high. Hope this helps.
Marianne
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I was on MediCare, with Part D coverage with Humana, in mid 2019 when I was prescribed Esbriet. I was told it had to go through a Humana specialty pharmacy, not where I normally got prescriptions. It was approved for a year with a copay of $1900 a month which was far beyond my ability to cover without going into credit card debt. After several attempts for assistance through different foundations I learned I made to much a year to quality…too much for some assistance, but not enough to afford the copay. Cedars got me in touch with Genetech who eventually provided it free. After those several months of wrangling I took it for about a month only to discover I couldn’t take it after breaking out in a rash. I hope you have a better resolution.
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Thank you Wanda and Marianne for your information. I’m currently speaking with Genentech about the programs available.
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Try CVS Specialty Pharmacy on line regular pharmacies don’t carry these meds as far as I know.
There are other specialty pharmacies out there Humana has one, probably others do too. Your Pulmonologist can hook you up with a way to get the meds.-
That’s part of my problem. My pulmonologist doesn’t really care about helping me in the process of getting the medication. As a result, I’m seeking a third pulmonologist opinion!
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I have UnitedHealthcare and Medicare coverage, and my Dr had no problem getting approval (his staff highly recommended Esbriet). I did have monthly liver checks since my liver was already somewhat compromised because of my drinking, but there was no side effects noted because of my taking of Esbriet. I get it through the UCSF specialty pharmacy here in San Francisco. Likewise I take Tyvaso for Pulmonary Hypertension, and had no problem getting approval, notwithstanding that this is an incredibly expensive drug (over $30,000 a month charged to my insurance company, with a $2,000 annual copay by me).
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Thank goodness for Medicare because we have UnitedHealthCare and they refused to cover my husband’s Esbriet even though his Pulmonologist told him he was doing great on it. I had to get Pirfenidone in India. I have a very bad taste in my mouth with UnitedHealthCare. I am happy it worked for you!
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You should report him or her to an advocate or the AMA. That is totally unacceptable.
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Genentech Patient Resource Center
Our center dedicated to getting patients and caregivers to the right resources.
Call us at (877) 436-3683 or (877) GENENTECH, Monday-Friday, 6am-5pm PT. -
My Dr. did for me, I thought because it is a specialty drug it had to be requested from a pulmonologist, there is a program to cover expenses through GENENTECH I thought. 877-436-3683 M thru F 6am to 5pm PT.
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I did the same by calling Genentech and they reached out and helped me.
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If you’re a US military vet, you can get it through the nearest VA Hospital pharmacy. If it’s not military-service-connected, there’s an $8.00 co-pay.
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I am in the same boat as William Kracke. My first year on it ran out last month and it took my Doc sending in the info to Express scripts X3 before they accepted and approved it. Plus every month I have to call in to refill it, so they have proof of life before they send out another 30 days, all my other meds from them are on a 90 day auto refill.
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I have been on Esbriet for 5 yrs CVS Specialty pharmacy has me reorder every month to make sure no problems have arisen since my last refill, the Dr. renews the script for 3 Mo’s at a time, never had to re-apply. I have never heard of Express scripts, Genetech is the distributor of Esbriet as far as I know. Look at other post on here for additional info. ie, Pete’s post and others of mine with phone #’s.
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I am a military retiree and have Tricare For Life/Medicare and am service-connected for IPF. It took nearly 9 months to get approved for Esbriet by the VA. It took another 2 years to see a good result in my PFTs. I was confirmed with IPF by biopsies in April 2020 and have been treated by Mercy system since diagnosed. The VA was funding my treatment until October of this year and abruptly cancelled my treatment authorization to include my medication. Unknown to me the VA had seen scarring on my lungs at least 15 years ago and did not tell me or feel there was anything to be concerned about. The VA told me that my treatment would be evaluated and would be started as if it was a new patient and all medicine would have to go through the authorization process again. Stress control is critical and you can imagine how this took me to a new low. A few days following this I had my regular appointment with my pulmonary team at Mercy. As always, my appointment began with the 6 minute walk. In under 2 minutes my O2 had dropped to 70% and my heart was at 150BPM — I went down hard. The stress got to me and changed my status and the future is now in question. My doctor suggested contacting my Senator. That afternoon I ended up in the E.R. and I then made contact with my Senator’s office. Less than 48 hours I was contacted by the VA and the Head of VA Medical Services agreed with my Senator that my treatment should remain with my doctor and he apologized for the actions of the individual at the VA. I then received a letter from the VA authorizing 6 months of medical care from Mercy. So, I will be dealing with this again in April 2024. I am very disappointed in the VA. I have been rated 10% disabled for IPF and 20% for presumptive Type II diabetes for herbicide exposure as far back as 1972.
Every breath I take is painful and I am using oxygen more often. We are just hoping for a possible new medication in the new year. Had I known why my breathing had been difficult years ago my doctor tells me that I might have been able to get a lung transplant, but my health and age have that ruled out.
I will see about Express Scripts, but they can be difficult to deal with.
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Have you applied to Genentech group for a free script. If you meet the requirements they can offer it for free. I am one of those people and very grateful for the script.
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generally you have to go through the “Speciality Pharmacy” division fo drug dispensers. to get these IPF drugs.
look up Speciality Pharmacy for CVS, as these drugs are very costly and must be dispensed through this delivery channel.
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