Expert Answers: Medicaid and Hepatitis C
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While amazing progress has been made in the treatment of Hepatitis C, the new drugs that are providing a cure for this disease come with a hefty price tag. Consequently, many people are struggling to find a way to pay for treatment. One topic that several of our community members continue to discuss is Medicaid, and if Medicaid will provide coverage for the new Hepatitis C Drugs. So, we asked one of our experts, Sue Simon, to provide some insight into this popular point of discussion.

Sue’s Response:
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Medicaid is a federal insurance program that is administered by individual states where patients live. It helps with medical costs for people with limited income. Each state has its own set of eligibility requirements and determines the scope of services for its enrollees. Although Medicaid is a federal program like Medicare, and follows federal laws, it differs dramatically in the restrictions that limit patient access.

In 2014, two new treatments, Harvoni and Viekira Pak were FDA approved for patients with hepatitis C. Patients and providers are excited about these new treatments as they eliminate the need for interferon, an injectable drug that actually made patients feel sicker than their disease. These medications have negligible side effects, and a much shorter duration than previous treatments. Best of all they are curing previous difficult to treat genotype 1 patients. It is a new and exciting era for people with hepatitis C. There are finally medications that cure a virus, rather than just help patients manage their illness.

The joy and excitement over the FDA approval of these wonder drugs has been overshadowed both by the exorbitant cost of the drugs and by the fact that there are people who know the treatments exist but cannot access them. It is heartbreaking to know that there are people living with a chronic sometimes fatal liver disease, and there is a treatment that will cure them, but they are being prevented from receiving it.

While the pharmaceutical companies, Gilead and AbbVie, who manufacture Harvoni and Viekira Pak, have generous patient assistance programs, many patients do not have the strength to do the work necessary to get help. For example, if a patient is turned down by Medicaid due to not having serious enough liver disease, they must appeal that decision. Once they are turned down the second time, they can go to the pharmaceutical company. But, the process is onerous. Let’s say Medicaid turned them down because they do not feel it is medically necessary to treat. The patient is Stage 3, not Stage 4, and in their state only cirrhotic Medicaid patients qualify for treatment. They must document everything about their chronic liver disease. There is a ton of paperwork that must be done by both the busy physician and the exhausted patient in order to receive treatment.

Some of the most common restrictions put in place by Medicaid are:

  1. Adherence – the patient must demonstrate that he will take his medication correctly
  2. Abstinence – the patient must be drug and alcohol free for a certain amount of time and prove it with blood and/or urine testing
  3. Co-infection – The patient must be co-infected with HCV/HIV
  4. Medical Necessity – the patient must have late stage disease
  5. Prescriber Restrictions – the patient must be prescribed treatment by a certain type of specialist or even a particular physician who may practice many miles away
  6. Retreatment Restriction – If a patient fails to respond to treatment he may not retreat for 2 years
  7. Medicine Replacement – if a patient loses a pill, it will not be replaced

Advocates, physicians and pharmaceutical companies are working hard to help eliminate these unfair restrictions. Hopefully, as new drugs are discovered and approved, the competition will help lower prices and remove restrictions. One can only hope.

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