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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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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:
SUPPORT
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. -
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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 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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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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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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