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For patients with hepatitis C seeking modern treatment options, many health plans force health care professionals use criteria that are clinically unsound.
For patients with hepatitis C seeking modern treatment options, many health plans force health care professionals use criteria that are clinically unsound.
According to researchers at Case Western Reserve University and Temple University, stringent Medicaid insurance requirements for coverage of direct-acting antivirals (DAAs) are cumbersome, arbitrary, and inconsistent with guideline-based treatment.
Of the more than 3 million people in the United States with hepatitis C virus (HCV) infection, more than three-fourths were born between 1945 and 1965. As a result, many patients with HCV receive prescription drug benefits through Medicare, and prescription drug benefit prior authorization criteria are a key part of obtaining access to this new set of highly effective medications.
Unfortunately in an effort to cut costs, government health plans have placed complex and burdensome requirements on providers in determining whether or not to cover the cost of a DAA for each patient with HCV.
To assess whether or not these coverage determination requirements are consistent with guidelines, researchers analyzed coverage requirements for Medicaid insurance carriers in Ohio and Pennsylvania. Several aspects of coverage determination were inconsistent with guidelines. For instance:
As a result of these arbitrary criteria, many patients are exposed to the risks of invasive liver biopsy, not for clinical reasons, but solely at the discretion of private insurance providers administering taxpayer-funded Part D programs on behalf of the United States government.