Hepatitis C-HIV Coinfection Under Medicaid Managed Care

Navigating prior authoization requirements for patients coinfected with hepatitis C and HIV remains a challenge.

About 3.2 million people have chronic hepatitis C virus (HCV) infection in the United States, and about 30% to 40% of those living with HIV/AIDS have co-infections with HCV.

New direct acting antivirals can cure HCV, but they are costly.

The price of these drugs is a "significant challenge" for many Medicaid programs, researchers from Amida Care in New York, NY reported at the 20th Annual United States Conference on AIDS in Hollywood, FL.

Amida Care is a community sponsored non profit Medicaid special needs plan that provides care to patients throughout New York City. It has 6000 cients who are HIV positive. To control costs while preserving access to these HCV drugs, Amida Care uses its own in-house prior authorization system to make sure patients are prescribed the drugs appropriately.

Each new case is received by an HCV clinical specialist, who makes sure the patient is tested for HIV viral load, HCV viral load and genotype, treatment history, renal function, and fibrosis test. Undetectable HIV viral load is a prerequisite for being cleared for HCV drugs.

Not having a low viral load is a common reason requests for HCV drugs for these patients get refused. Under the Amida system, if the HIV viral load is unsuppressed, the patient gets HIV treatment until it goes down.

The program got results. In 2015 there were 450 prior authorization requests for HCV antivirals, and only 40 were denied: some for incomplete data, some for unsuppressed HIV viral load, others because patients needed different drug regimens.

Screening the patients to see if they were appropriate candidates for direct-acting antivirals was successful, AMIDA concluded.

"Denial reasons supported clinical appropriateness, member readiness as well as cost-effective therapeutic alternatives.