Thank you for sharing this information @bornwithhepb. Other alternatives to consider include switching over to generics of entecavir or TDF, which may be cheaper at GoodRx/similar stores. Of course, everyone should first consult with their health professional before changing their medications!
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Sorry I should clarify when I said âout of optionsâ I meant out of options in terms of financial coverages for TAF outside of self pay. Like Dr Tu said there are other options in terms of alternative treatments.
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I have been working with my doctorâs office on the appeal since I got the CVS letter last month. They just informed me we could not submit the appeal until we get a denial in January 2026. Le Sigh 
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Thanks for keeping us updated on your situation, @bornwithhepb. I encourage others to share their experiences so that we can have a broader picture of whatâs happening on the ground.
TT
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I also received the same Aetna/CVS caremark letter, and asked my doctor if I can get an exception to continue with Vemmlidy. I got the similar response with @bornwithhepb, quote âGastroenterology is planning on submitting the PA/plan exception request after January 1st in an attempt to continue your coverage for Vemlidy. The PA cannot be submitted before the new coverage policy goes into effect on 1/1/26 which is why they are unable to submit this now. As Gastroenterology recommended, try and fill your prescription at the end of December to ensure your have enough supply while they work on submitting the PA in January.â
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I came across a video the other day that discussed an external review process for patients under the Affordable Care Act (ACA). If the individual is denied both through the initial and appeal process, they can seek an external review.
Below is more information on this. It might work for many patients who stand to lose Vemlidy coverage in a couple of weeks. There is an opportunity to request an expedited review. This review is conducted by an outside entity contracted by the US Department of Health and Human Services. More information is available below (it is a bit lengthy, but helpful).
A General Overview of the HHS-Administered Federal External Review Process
If a health insurance plan denies a benefit, refuses to pay for a service that has already been
received, or rescinds coverage, this is called an adverse benefit determination. If a health
insurance plan upholds its earlier adverse benefit determination, this is called a final internal
adverse benefit determination.
Consumers may ask for an external review of a final internal adverse benefit determination. In
some instances, consumers may ask for an external review when the initial denial (adverse
benefit determination) is made.
A consumer or their authorized representative (called the âclaimantâ) may file a written request
for an external review.
A consumer may file a request with MAXIMUS within four months after the date of receipt of a
notice of an adverse benefit determination or final internal adverse benefit determination.
Consumers may send requests by mail, facsimile, email, or through a secure, online portal.
While we will still continue to accept external review requests submitted by email, mail, or
facsimile, we strongly encourage all issuers and claimants who are able to do so to use the online
portal to submit their review requests.
After MAXIMUS receives an external review request, MAXIMUS contacts the health insurance
issuer. The issuer must provide all documents related to the adverse benefit determination to
MAXIMUS within five business days.
Claimants may also submit any additional information they want MAXIMUS to consider during
the external review.
MAXIMUS will review all of the information and documents that are submitted with your
request, as long as they are submitted on or before the four-month deadline.
For a standard external review, the MAXIMUS examiner must provide written notice of the final
external review decision as expeditiously as possible and no later than 45 days after the examiner
receives the request for the external review. Claimants will receive external review
determinations in writing.
For urgent care situations, claimants may file an expedited external review for either an adverse
benefit determination or a final internal adverse benefit determination if:
- An adverse benefit determination involves a medical condition of the claimant for which
the timeframe for completion of an expedited internal appeal would seriously jeopardize
the life or health of the claimant, or would jeopardize the claimant's ability to regain
maximum function and the claimant has filed a request for an expedited internal appeal;
or - A final internal adverse benefit determination involves a medical condition where the
timeframe for completion of a standard external review would seriously jeopardize the
life or health of the claimant or would jeopardize the claimant's ability to regain
maximum function, or if the final internal adverse benefit determination concerns an
admission, availability of care, continued stay or health care service for which the
claimant received emergency services, but has not been discharged from a facility.
For an expedited external review, the MAXIMUS examiner must provide notice of the final
external review decision as expeditiously as the medical circumstances require and within 72
hours once the examiner receives the request for the external review. MAXIMUS must deliver
the notice of final external review decision to the claimant and the health insurance issuer as
soon as possible. This notice can be initially provided orally but must be followed up in writing
within 48 hours.
Decisions made by MAXIMUS are final, and there is no further review available under the HHS-
Administered Federal External Review Process after a claimant receives a decision. This
decision is binding on both the claimant and the health plan or issuer, except when there are
other remedies available for the claimant under federal or state law, such as filing a lawsuit. If
you are a consumer, health insurance issuer, or health care provider interested in learning more
about the HHS-Administered Federal External Review Process, please visit the CMS External
Appeals web page at: /cciio/Programs-and-Initiatives/Consumer-Support-and-
Information/External-Appeals or call toll-free at 1-888-866-6205.
Here is a link to the page:
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Hi @chari.cohen Iâve been monitoring for the public sign-on letter link but havenât seen it yet. Is it still in preparation, or did I possibly miss it? If available, could you please share the link here?
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Thanks @Bansah1, great information. Do you have a specific link to where the information is located?
Cheers,
TT
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I added the link to the initial post. I thought I added the link, but I did not. It is added now, I hope it is a fair process with great outcomes for all the patients that need it now. Best, Bansah1
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I want to share some good news: my Prior Authorization ¶ for Vemlidy has been approved and is valid for another year. Iâm sharing the process I followed in case it helps others in a similar situation.
December 2025:
I learned about the upcoming formulary change and contacted my doctorâs office right away. I did my own research and gathered supporting reasons for remaining on Vemlidy based on my lab results and family history, and shared these with the nurse who was helping me. I was also advised to draft a personal statement explaining why I switched from TDF to TAF. At that time, I was told an exception request could not be submitted until January, when the formulary change officially took effect.
January 2, 2026:
I requested a refill, which was promptly rejected due to lack of coverage. I contacted the nurse the same day to let them know about the rejection so they could start the process. Later that day, I received a notification from Caremark that a Prior Authorization request had been submitted on my behalf.
January 5, 2026:
The PA was approved. I called Caremark to confirm the details and was told that this approval is classified as a Prior Authorization (not a formulary exception) and is valid through January 5, 2027. This means I should be able to request a refill on January 1, 2027 under the new benefit year, while submitting a new PA at that time.
Iâm hoping Vemlidy remains on the formulary going forward so we donât have to repeat this process every year with uncertainty.
Please be your own advocate. Wishing everyone good luck navigating this.
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So outside of potential kidney and bone loss, is viread worse than vemlidy? I thought one of the side effects for vemlidy is high cholesterol. Ive been trying to get my cholesterol down but havent been successful. When i traced my labs back to when i started to take meds (vemlidy), i noticed my numbers were higher (in the hundreds). No other explanation other than i started taking medication. My diet was pretty much the same, if anything im eating and exercising more now.
Now that my insurer doesnt accept vemlidy, im thinking maybe it isnt a bad idea to make the permanent switch to viread. I have a couple of bottles before i have to take viread.
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@dotbammer Yes I have heard about the high cholesterol issue with Vemlidy. Also, not everyone on Viread experiences kidney damage or bone loss. If you think that your high cholesterol issue caused by Vemlidy, I think itâs worth a try to switch. There is also entecavir, which is available as a low-cost generic.
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Fantastic news @bornwithhepb! Your experience and story really helps others out there navigating the system.
@dotbammer, it is definitely worth considering, but please speak to your health care professional before making any changes to your medication schedule.
TT
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My initial PA was denied but a following appeal finally approved for 1 year
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I received the same message from Aetna/CVS caremark last year about Vemlidy will be no longer covered starting from 1/1/2026. The Aetna representative told me no worries just submit a prior authorization in Jan, 2026 when requesting refills. So I thought it should be alright.
I requested the refill early Jan. My doctorâs office finally submitted the prior authorization ¶ but it was denied by Aetna 2 days later. I called the CVS caremark prior authorization team. They told me the PA was lack of some information and my doctorâs office needs to provid additional information to submit a new PA.
This is very frustrating. Iâm running low on my Vemlidy pills. I just followed up with my doctorâs office and hopefully somebody can help me soon.
I saw there was a pettion led by HepB foundation in 2023 to CVS caremark/Aetna. Does anyone know if they will have a similar one in 2026?
I guess Iâm running out of options:
-
Keep trying to push the appeal by my doctorâs office
-
Swith to TDF
-
Consider to get TAF outside of US like China or India if they can do telehealth. The shipping might be complicated and takes long
@Mocha Sorry to hear youâre having trouble. I probably wouldnât recommend 3. Have you already tried TDF and/or entecavir? If youâve tried both and had to stop due to side effects, then I really donât have great advice, other than to continue to pursue the prior authorization. However, if you havenât tried those other options, I think it would be much better to switch, rather than risking running out of Vemlidy.
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Yes, I donât want to miss any dossage. I will call the doctor office again tomorrow to see what to do. My next doctorâs appointment will be in March. Itâs also frustrating that you need to book months ahead to see a specilist in US.
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Best of luck! Oftentimes, the doctorâs office can send over a prescription even if you canât get an appointment, so that you donât run out.
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Hi @Mocha,
Welcome to the community. I agree with @et5656 on this. Doctorsâ offices can be busy, but send gentle reminders to ensure that someone is following up on this, and that the missing information is furnished to your insurance so you can get Vemlidy approved. This is important, so ensure you follow up a lot on this. They might not appreciate you calling often, but it helps. In my experience, making the effort and showing that you care about your own health encourages the staff members to do the same. Advocating for yourself here is crucial.
Please keep us posted on how things go. Best, Bansah1
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Thanks for the reply! I guess I am out of options and have to switch to TDF.
This is very frustratingâŠI canât use the newest and safest medication, which is invented and produced in USA, since itâs not covered by insurance and $1500 cash price. Meanwhile, my friend in China only pay $50 cash price or $20 with insurance for Vemlidy.
if anyone knows a doctor who is willing to send an exception letter. Please let me know. Iâm considering switching to a new doctor.
My doctor refused to send the exception letter. She said the bone density issue will be the same for both TDF and TAF. She said there potential side effect of kidney damage of TDF but she will keep monitoring it.