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RI Medicaid Denied 65% Of Requests For Hepatitis C Drugs

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Hepatitis C may not take as big of a chunk out of the state’s Medicaid budget as previously projected. One reason? A majority of patients who requested...

Hepatitis C may not take as big of a chunk out of the state’s Medicaid budget as previously projected. One reason? A majority of patients who requested treatment have been denied.

New drugs for hepatitis C can cure the disease in most patients. But they’re so expensive, health insurers have placed limits on who qualifies for them. Rhode Island’s Medicaid program restricts the drugs to people with advanced liver damage and those who have abstained from drugs and alcohol for at least six months.

Medicaid officials say 65 percent of requests (called "pre-authorizations") for the drugs have been denied because patients did not meet those criteria. One hundred ten people have been approved. That will cost the state much less than previously projected.

The American Association for the Study of Liver Diseases recommends patients start treatment before their liver disease advances. But many health insurers around the country, as well as prisons, are prioritizing patients with the most severe disease because of the large numbers of people infected with hepatitis C.

A recent study published in the journal Annals of Internal Medicine evaluated state Medicaid policies for treating hepatitis C with drugs like Sovaldi and Harvoni. The authors found that a majority of states restrict treatment to patients with advanced fibrosis, or scarring, of the liver. They also found about half of states require some abstinence from drugs and alcohol, and more than half require urine drug screenings.

Medicaid reimbursement criteria for the hepatitis C drug sofosbuvir, based on documented liver fibrosis stage required for reimbursement. The higher the score, the more advanced the scarring of the liver.
Medicaid reimbursement criteria for the hepatitis C drug sofosbuvir, based on documented liver fibrosis stage required for reimbursement. The higher the score, the more advanced the scarring of the liver.