Health Care Plans Deny Coverage for Modern Hepatitis C Therapies Based on Arbitrary Criteria

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:

  • To obtain coverage, the amount of time between submission of blood test results and coverage of DAAs ranged from 30 days to 6 months, which serves no clinical purpose
  • Providers must document presence or absence of past or present psychiatric disorder in all patients, despite the fact that DAAs do not cause psychiatric side effects
  • Fibrosis scoring using an invasive liver biopsy is required for virtually all plans, despite the fact that less invasive methods are available, and patients with less severe fibrosis generally denied access to DAAs

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.

Click here to continue reading on CURE Hepatitis C.