Starting July 1, patients battling hepatitis C in Delaware will have newfound access to direct-acting antiviral cures – a victory now shared with patients in New York, Pennsylvania, Florida and Washington. Opting for access aligns these states with Medicaid’s mission and federal law; it may also save money over the long term. New data from The International Society for Pharmacoeconomics and Outcomes Research show that unfettered access for Medicaid patients with hepatitis C can save nearly $12,000 per patient while also improving quality of life.
But access wasn’t the initial response for many state Medicaid systems. When the first hepatitis C cures arrived on the market in 2013, high prices led many states to impose multi-step prior authorizations. Several states required that patients demonstrate advanced liver damage to access the cures. Still others limited use by allowing only specialty physicians to prescribe the treatment.
In November 2015, the Centers for Medicare and Medicaid Services stepped in with a letter reminding state centers of their responsibility to beneficiaries. CMS warned that withholding care could violate federal law.
Connecticut was a trailblazer, with the state’s Department of Social Services making hepatitis C cures “preferred drugs” – readily available to Medicaid patients beginning in July 2015. But in several states, it took patient advocacy and legal action to generate change.
- Delaware. Under threat of legal action, state Medicaid officials agreed to update their coverage policy. The state will phase in expanded access beginning July 1, with all hepatitis C Medicaid patients, regardless of liver function, qualifying for treatment by January 2018.
- New York. Patient advocates’ pressure on New York’s Drug Utilization Review Board led the state to eliminate requirements that patients have at least Stage 3 liver fibrosis before obtaining curative treatment.
- In May, a federal judge ordered the state of Washington to eliminate its Medicaid policy’s coverage exclusions for hepatitis C cures.
- Pennsylvania’s Pharmacy & Therapeutics Committee voted to remove restrictions that required disease severity for Medicaid patients to access treatment.
- Complaints that Florida was violating patients’ rights under federal Medicaid guidelines led officials to remove access restrictions requiring patients to show advanced liver damage.
Patients in many more states are still fighting. And access for patients covered by private insurers presents still another battle.
But for Medicaid patients in Delaware and other states that have prevailed, the promise of life without hepatitis C is finally within reach.