requirements for Hep C treatment are wrapped in red tape

Current Hepatitis C Treatment Restrictions

For any medical condition, there are specific treatment options. In some cases, certain drugs may not be recommended for safety reasons. For example, some drugs may interact with each other or cause severe side effects for certain groups of people. Other drugs may cause allergic reactions. These are all medical restrictions.

However, there are also non-medical reasons treatments are restricted. These are often determined by insurance coverage. Some drugs that are expensive may require specific conditions before an insurance company will help pay for them. This can create barriers to care and prevent people from getting the treatment they need.

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Were you able to get treated for Hepatitis C immediately following diagnosis?

The most common non-medical treatment restrictions for those with hepatitis C include:

  • Recent or current substance use (alcohol or drugs)
  • Extent of liver damage (fibrosis)
  • Access to a hepatitis C specialist

These restrictions can create unfair barriers to accessing treatment, as well as unnecessary stigma.

Tracking barriers to hepatitis C treatment

There are many different insurance companies and types of support. This can make it hard to track patterns. However, Medicaid is a large insurance program that can be studied. Many people in the United States are covered by Medicaid.

The Center for Health Law and Policy and the National Viral Hepatitis Roundtable are advocacy groups that study hepatitis C treatment through Medicaid. They reviewed past medical records from 2017 to 2020 to track restrictions by state.1,2

Sobriety

Before 2017, many states required that a person stop using drugs or alcohol before they received hepatitis C treatment. The rules for how long a person must be sober and what other support they needed before treatment (like counseling or intensive substance use treatment programs) were not always clear.

Between 2017 and 2020, 21 states loosened their sobriety requirements for treatment. However, 28 states still have some sort of sobriety barrier. These can range from simply being offered substance abuse counseling to up to 6 months of complete sobriety before starting treatment. In some cases, sobriety may be monitored using drug tests.1,2

As of mid-2021, the following states had sobriety restrictions:1,2

  • Completion of screening questions on substance use or counseling: Alaska, Colorado, Delaware, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Maryland, Minnesota, Montana, New Hampshire, Oklahoma, South Carolina, and Wyoming
  • One month of sobriety: Florida
  • Three months of sobriety: Arizona, Iowa, Kansas, North Dakota, Texas, and West Virginia
  • Six months of sobriety: Alabama, Arkansas, Mississippi, Nebraska, South Dakota, and Tennessee

Fibrosis

Years of hepatitis C can lead to scarring of the liver. This scarring is called fibrosis. It is graded on a scale from 0 to 4, with 4 being the most liver damage. Some states limit access to treatment based on the stage of fibrosis. In these cases, treatment is not covered until a person’s fibrosis has progressed a certain amount and significant damage is done.

On a positive note, between 2017 and 2020, 32 states loosened or got rid of their fibrosis restrictions for treatment. Only 4 states currently have fibrosis restrictions:1,2

  • Minimum of stage 2 fibrosis: Nebraska and Texas
  • Minimum of stage 3 fibrosis: Arkansas and South Dakota

Access to a specialist

Another common treatment restriction in hepatitis C involves who can prescribe the medicine. In some states, a hepatitis C specialist is the only doctor who can prescribe treatment. These specialists include hepatologists (liver specialists), gastroenterologists, and infectious disease doctors. In other states, a non-specialist can prescribe treatment, but a specialist must have at least been consulted (asked) about the specific situation.

Thankfully, these restrictions are lifting a bit, just like those for sobriety and fibrosis. In recent years, almost half of all states have made adjustments in this category. States that currently have prescriber restrictions include:1,2

  • Requiring at least a consult to a specialist: Arizona, Colorado, District of Columbia, Hawaii, Illinois, Iowa, Mississippi, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Texas, and West Virginia
  • Only a specialist can prescribe: Arkansas and New Jersey

Why are restrictions a problem?

With the development of direct-acting antiviral drugs for hepatitis C, we now have a treatment option with very high cure rates. Preventing people from using these helpful and life-saving drugs for non-medical reasons can lead to unfair treatment.

Treatment restrictions can increase stigma and access to care for those navigating substance use disorders. It can also impact those who do not live close by to specialists who can prescribe treatment. Access to treatment can also change based on your insurance provider. The rules listed above are for those on Medicaid. Other insurance companies may have more or fewer restrictions.

Many advocacy groups are working hard to continue breaking down barriers and loosening restrictions. Several of these groups have a goal of reducing all restrictions around hepatitis C treatment across the United States in the coming years.

The Hepatitis C State of Medicaid Access database is a great place to see the specific restrictions in your state.

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