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A damaged liver is bandaged by dollar bills and floats about the ground where pills lay scattered.

What To Do When You Hear “You’re Not Sick Enough for Treatment”

Chronic hepatitis C affects nearly 3.5 million people in the United States and causes 19,000 deaths a year. Direct-acting antiviral drugs are available to treat hepatitis C and almost always can cure the disease.1,2 Still, it is not unusual for patients with hepatitis to hear, “You’re not sick enough for treatment”. Our 2018 Hepatitis C In America survey found that for 10% of patients, this is why their hepatitis C remains untreated.

The struggle for treatment

The World Health Organization recommends antiviral treatment be given to all patients with hepatitis C, regardless of how far the disease has progressed.3 Treatment for hepatitis C is simple and effective. The treatment is a 12-week course of pills taken by mouth, has few side effects, and has a 95% cure rate.1,2 Sadly, many patients are denied medication. Medication to treat hepatitis is extremely expensive, costing up to $95,000 for a 12-week course.1 Because of this, it is difficult to get insurance companies to cover the cost of treatment. In fact, 1 in 3 patients with chronic hepatitis C is denied treatment. And for patients with private insurance, this number is even higher— over 50% of patients can’t get treatment.4

What does “not sick enough for treatment” mean?

Even though the World Health Organizations recommends antiviral treatment for all patients with chronic hepatitis C, many patients are denied medication. This is likely due to the high cost of treatment, and insurers put restrictions on who will be approved for prescription cost coverage. Many insurers deny reimbursement unless the patient is in advanced stages of disease, or in liver failure. Other restrictions, such as not using alcohol or drugs, or requiring a referral from a specialist may also be needed to get cost coverage.1,2,4,5 This is bad news for patients with hepatitis C. If left untreated, chronic hepatitis C can put patients at risk for many other complications, such as liver damage, cardiovascular events, or cancer.4,6 Lack of treatment also contributes to the ongoing transmission of disease.4

What to do if you can’t get treatment

Early detection and treatment are the best course of action for patients with chronic hepatitis C.7 So what happens if you are prescribed an antiviral medication, but you cannot afford it, or your insurance company denies cost coverage? Older forms of treatment are no longer recommended to treat hepatitis C because of serious side effects that go along with them, so if coverage is denied, there are few other options for patients.6

Sometimes, it takes extra work from the healthcare provider to ensure cost coverage for their patients. Patients can appeal if their insurance company denies treatment. This means, trying again to get coverage. Doctor’s can write letters outlining the need for treatment, and this can sometimes help.6 Another option is to reach out to the drug company directly. Many drug companies offer patient assistance programs, which may include free medication or assistance with payment.5,6

  1. Livingston, S. Insurer denials for hepatitis C treatment remain high. https://www.modernhealthcare.com/article/20180607/NEWS/180609943/insurer-denials-for-hepatitis-c-treatment-remain-high. Accessed 3/13/19.
  2. Mera J, Reilley B, Leston J, Stephens D. In a critical state: ongoing barriers to treatment for hepatitis C virus (HCV). Am J Med. 2018. https://www.amjmed.com/article/S0002-9343(18)31072-6/fulltext. Accessed 3/13/19.
  3. World Health Organization. Web Annex 1: When to treat. https://apps.who.int/iris/bitstream/handle/10665/277213/WHO-CDS-HIV-18.34-eng.pdf?ua=1. Accessed 3/13/19.
  4. Kaltwasser J. One-third of chronic HCV patients get denied direct-acting antiviral therapy. MD Magazine. https://www.mdmag.com/medical-news/onethird-of-chronic-hcv-patients-get-denied-directacting-antiviral-therapy. Accessed 3/13/19.
  5. Kaltwasser J. High cost of hepatitis C drugs leads to lengthy battles for access to therapies. MD Magazine. https://www.mdmag.com/medical-news/high-cost-of-hcv-drugs-leads-to-lengthy-battles-for-access-to-therapies. Accessed 3/13/19.
  6. Healthline. The progression of hepatitis C: what are the stages? https://www.healthline.com/health/hepatitis-c/stages-progression#outside-factors. Accessed 3/13/19.
  7. Healthline. Will your insurance cover hepatitis C treatment? https://www.healthline.com/health/hepatitis-c-insurance-coverage#coverage. Accessed 3/13/19.

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