Federal officials say state Medicaid agencies may be going too far when it comes to restricting access to new hepatitis C drugs. Rhode Island, like many states, requires Medicaid patients to meet a list of criteria before doctors can prescribe them the new medications. But those criteria may be too restrictive.
New medications like Sovaldi and Harvoni have been shown to cure most hepatitis C infections. But they’re expensive – tens of thousands of dollars a course. So Rhode Island Medicaid prioritizes coverage for patients who already have extensive liver damage (they must score F3 on the fibrosis, or liver scarring, stages 1 - 4. For patients co-infected with HIV, that score can be F2). They must also be drug and alcohol free for six months before doctors can write them a prescription. The requirements appear on something called a pre-authorization form, which doctors must fill out to request the drugs before prescribing them.
But in a letter to states from the Centers for Medicare and Medicaid Services, officials say these requirements may “unreasonably restrict access” to these drugs. In the letter, Acting Director Alissa Mooney DeBoy writes:
"CMS is concerned that some states are restricting access to DAA [direct-acting antiviral] HCV [hepatitis C virus] drugs contrary to the statutory requirements in section 1927 of the [Social Security] Act by imposing conditions for coverage that may unreasonably restrict access to these drugs. For example, several state Medicaid programs are limiting treatment to those beneficiaries whose extent of liver damage has progressed to metavir fibrosis score F3, while a number of states are requiring metavir fibrosis scores of F4."
If the requirements are loosened, more Rhode Islanders could qualify for treatment. But the state’s already-strained Medicaid budget could also take a hit.
Medicaid officials were not immediately available for comment.