The Medicaid Debacle

[AWorriedMom]

There seems to be a lot of confusion over whether patients who are insured by Medicaid  can get Harvoni and Viekira Pak covered. There is no easy answer to this because each State has their own requirements for who is eligible for coverage. Some of the restrictions are ridiculously severe. Many of the States make patients jump through hoops or deny coverage for anyone who is not at death's door. That one makes me crazy as I relate it to making cancer patients wait until they have advanced stage disease to get their chemo....and we know that doesn't happen. Bottom line is that Medicaid patients must do their homework because it is a government program where each State has its own set of criteria better known as prior authorization. There is no blanket statement that Medicaid does not pay. While I am sure that is true in some states, it isn't true in all states.

Some of the more common restrictions are patients must have at least Stage 3 (Metavir) disease; some States allow only one treatment per patient (What is a relapser supposed to do?); Some have crazy co-pays; A few will only allow genotype 1 patients to treat and the heck with geno 2, etc. There are many barriers.

I thought it might be helpful if anyone knows what their State requires, they can post in this thread and let others know. And remember that these rules are changing constantly so try and give the newest information.

[Dee1956]

Here is a blurb about Illinois, they have changed their criteria for treating HCV.  Some of the states are restricting access to HCV meds to only people with cirrhosis. The law said they have to pay but it allows them to restrict access.   I think I read 8 of them, one being Oregon.

    The high price of Sovaldi drove Illinois Medicaid’s hepatitis C spending to $22 million for the fiscal year ending June 30, 2014, up from $6.7 million the previous year, according to the Illinois Department of Healthcare and Family Services.

    Facing higher costs, Medicaid officials stopped paying for any but the sickest patients to get the new drugs, drawing criticism from some liver doctors who have said the state is preventing them from properly treating their patients. […]

    In addition to limiting Sovaldi to the sickest patients, the Illinois Department of Healthcare and Family Services has set two dozen criteria for who can get the drug, including requiring that patients have no evidence of drug or alcohol abuse in the last 12 months and barring treatments not approved by the Food and Drug Administration.

    Spending on hepatitis C treatment dropped from $1 million per week to about $200,000 per week after the department adopted the restrictions, said Dr. Arvind Goyal, the department’s medical director. […]

    The state did not start keeping track of how many patients it denied Sovaldi until October, Goyal said. For the month of October, 43 of 50 patients who requested the treatment were denied, according to the department.

The problem is that state policy could be increasing state costs down the line, when denied Medicaid patients wind up hospitalized.

* And, of course, Americans are getting the shaft…

    Although Sovaldi cures hepatitis C in more than 90% of those who for whom it has been prescribed, the 12 week course of treatment in the U.S. is $84,000, which comes to $1,000 a pill.

    While curing hepatitis C saves lives and prevents a lot of downstream healthcare costs for patients who, without this drug, could ultimately develop liver cancer or require a liver transplant, payers and politicians are in an uproar for a variety of reasons, not the least of which is that the drug is priced much higher in the U.S. than in the rest of the world. For example, in Europe, where the government negotiates the price, Sovaldi’s price tag is on the order of $55,000/patient.

    While Gilead’s pricing strategy in the U.S. can be challenged, it has certainly taken a responsible approach to Sovaldi pricing in poorer countries. In Egypt and most recently in India, the cost of Sovaldi is going to be only $900/patient

- Posted by Rich Miller        

[Dee1956]

I think that after Sovaldi came out with the $1K price tag, states started to pay attention and they realized they can't afford this.
I do see that 25 states have signed an agreement to cover Harvoni and Viekera so that is good.  Other states are working on restrictions.
It is frustrating to me to see them just starting to pay attention to tx for HCV as if it was really cheap before Sovaldi, it was just a longer more harsh tx.

Thanks
Dee

[Magnum]

Something doesn't sound right. I had my transplant in Illinois and the rules then (Dec. 2013) was 6 months for street drugs, alcohol and smoking...

Magnum

[Dee1956]

Illinois has placed a restriction that no one can have had any alcohol in 12 months.  Right before I was diagnosed, I went to visit my son.  We had some drinks which I rarely had.  So...then with this rule I would have had to wait a year.  Sorry I think this is wrong.  I understand illicit drugs but how many other people have to be drug tested before they are given a drug that could save their life? I can see the thinking is changing but not fast enough to save lives.

http://www.chicagotribune.com/news/ct-medicaid-hepatitis-met-20141116-story.html#page=1

[Dee1956]

Hi it is not that they don't have the facts, they are just talking about the most expensive drug at the time. If you do a search for State Medicaid not paying for HCV Meds, you will see that most of the articles are only discussing the new drugs.  I don't think there is a problem with ribavirin or interferon being part of the tx.
Sorry about using an older article.  I was trying to answer AWM's question about Medicaid in certain states.  It seemed that article covered most of the States.  I was not trying to show recommended treatments.  Just what State Medicaid was doing in each State.  I am sorry I confused anyone

I just read that as of April 8th Texax is going to pay for Viekra, I am only talking Medicaid here.
Unfortunately, people who are on Medicaid are barred from getting any help from the drug manufacturer.
That is why this is a big deal for anyone on Medicaid.

When I mentioned the governor of California, I was just trying to say that people are coming around, not saying that would cover every person.  Just trying to say that it is progressing.  I was still trying to answer AWM's question.

Unfortunately, HCV has always had such a stigma, no one discusses it so no one was ready for this ground breaking tx to come along.  

Again I am really sorry if I confused anyone, I was trying to answer the original question.

[keepingOnkeepingOn]

I'm glad you clarified Dee, because on the directions with prescriptions it says to not use Solvadi alone. That means they don't have all the facts.

[dontworry_behappy1]

Transplant is on the high priority list for treatment.

Hepatitiscguidelines.org

[Magnum]

When my transplant doctor applied for Harvoni, I was concerned that they would refuse it due to the cost. He assured me that because my transplant cost was nearly $1,000,000, the insurance company does not want to fund that again, so he said rest assured they will not deny you. They didn't...

Magnum

[dontworry_behappy1]

Take a look at the guidelines for treating hepatitis C below

http://www.hcvguidelines.org/full-report/when-and-whom-initiate-hcv-therapy

California has treated 315 inmates for a cost of just under 30 million.  There is over 50,000 inmates in California with Hepatitis C.   So California can treat 3000 people in california for 300 million dollars the Governor has set aside.  That includes the Public population.  But if you have insurance that is a different set of rules.  You will be treated.

As I remember the 6 month rule for drugs and alcohol use isn't new.  This has been an argument here before.   All you have to do is not test positive
for six months.   Treatment is easier than when we treated.  I agree.  I was so sick I couldn't go out of my house.  But that has changed.  I wonder how much Incivek was shipped and not taken.   We talk how expensive the
new treatment drugs are.  Do you remember that Incivek was like 80,000+
for a 12 week course.  And that didn't include the Ribavirin and Interferon.

If you have private insurance its a very good chance you will be treated.
Because if you are denied you go straight to the drug company that makes
the drug and get them anyway.

As far as stop paying for Hepatitis C treatment except for the sickest?
You have to start somewhere.  Just treating everyone who has Hepatitis
C in California would Bankrupt the entire state.  

There are grants etc etc....that can be had to help pay for the cost of hepatitis C treatment.  Maybe they should make it mandatory  that Americans are tested for Hepatitis C.   Its now just for the high risk and is recommended to babyboomers.  Do this and stop funneling billions of dollars to fund everybody and there brother to educate the public about Hepatitis C.   Its complicated.  

  

[Dee1956]

As I searched I found some good news, 25 states have banded together to get their patients Viekira,  They do have to meet certain requirements but at least they are going to be able to get it.

One disturbing requirement that I have seen is that you can't have had any alcohol in 6 months, one state is requiring 12 months. ludicrous.  One state is only going to give out prescriptions 2 weeks at a time and if not refilled that is it, no more chances. I realize the newer tx's are easier however I was so sick while on tx, if it had not been shipped to me monthly I don't know what I would have done.

I also read that California governor has set aside $300 million to treat California residents with HCV.

Things are looking up :)

http://themissouritimes.com/16195/press-release-missouri-part-25-state-consortium-designates-new-hepatitis-c-drug-medicaid-patients/

[Dee1956]

When I searched for States where Medicaid is paying for HCV medications, I found the first article. The I found that in Nov Illinois had stopped paying for new HCV drugs except for sickest people. It isn't a matter of people not knowing how to deal with doctors as much as it is about States that don't have the money. I hope that as time goes by they will come up with a better plan than just saying no to new HCV meds

[Dee1956]

PS they are referring to Sovaldi alone because of the cost of the Solvaldi.  I didn't realize how bad it was for those on medicaid until Sarah shared her story about Oregon and how hard it was for her to get a doctor to prescribe the medications.

[Dee1956]

Hi I had posted because it showed what Medicaid was planning on doing with the new drugs which AWM asked. There are 8 states that are not willing to treat with new drugs which would be Harvoni or Sovaldi. I got the impression that there were problems because Medicaid in some states doesn't want to pay for new drugs. They didn't mind paying for interferon and Riba. This was an article that came out right after Harvoni was approved. It sounds like right now it is a case by case but soon, for medicaid in various states, there will be more restrictions. I hope not yeah Mississippi!

[keepingOnkeepingOn]

{{scratching head}}

Their use of the word "Solvadi" is confusing.

Harvoni contains Solvadi/Ledipasvir

Solvadi must be used in a combo and not as a stand alone medicine. Thus the use of Solvadi/Olysio (S/O) or Solvadi/Ribaviran (S/Riba) OR Solvadi/Ledipasvir (Harvoni)

Solvadi is in each treatment so why is the story referring to just Solvadi?

[dontworry_behappy1]

What seems to be the issue is those receiving government benefits only and new to insuance. Of course insurance companies will make you jump through hoops.   That's the process and practice of a cost efficent  insurance companies.   I think many don't know how to deal with thier own insurance company.  Lots of people have insuance for the first time in thier lives.   And we are talking about babyboomers who are older adults.   Health  Insurance is complicated.  Gilead is willing to help and even will contact your insuance company for you.  

"California Public Health" gives thier details of Hepatitis C Treatment on its government website.    

[patra_]

If I read Dee's post correctly, it seems to me Mississippi "Gets It" meaning they understand the sooner they treat, the easier the cure and, the less likely to have OTHER resultant problems, OR retreatment, THUS saving BIG $$$$ in the long run!

Way to Go, Mississippi!!

Pat

[AWorriedMom]

Good find. We can see from this article that many States are still in flux tryjng to figure out the best way to handle this. It is true that there just is not enough money to treat everyone. One one hand it is great that Gilead is being so generous with who gets assistance. On the other hand if they would have priced their drugs more appropriately perhaps more could be treated.

[AWorriedMom]

Yes, but just because they state who should be treated, doesn't always mean the insurance companies agree or anyone follows suit. It's a mess out there.

[dontworry_behappy1]

"Hepatitiscguidelines.org" clearly states who should be treated.  The 2015 version tells the current recommendations.  I'm not saying I agree but this is what is being followed.  Pretty clear presentation of who to treat.

[Dee1956]

I found this article, thought it might help, there are 8 with the rules much like Oregon, others are working on theirs, might be out very soon


Reform Update: Medicaid programs crafting limits on Harvoni usage
By Virgil Dickson  | October 21, 2014
Which Medicaid beneficiaries will have access to Gilead Sciences' newest high-cost hepatitis C treatment, Harvoni, and when they'll get that access, now depends on prior-authorization criteria being hammered out by various state agencies.

Most will likely limit Harvoni use to patients dealing with liver failure, as 35 states now do for Gilead's Sovaldi. Some may adopt restrictions such as banning those dealing with drug and alcohol addiction from getting the specialty drug, or limiting who may prescribe it to only board-certified gastroenterologists, hepatologists or infectious disease physicians. Another option is implementing the so-called “once in a lifetime” rule, which allows Medicaid patients only one chance at treatment.

Federal regulation stipulates Medicaid agencies must cover Food and Drug Administration-approved drugs marketed by companies that have negotiated rebates with the federal Medicaid drug-rebate program. Gilead participates in that program. Federal law also allows states the discretion of implementing prior-authorization criteria as they see fit.


Related Content
Gilead Sciences gets go-ahead for Harvoni, its second high-priced hepatitis C drug
Harvoni was approved by the FDA Oct. 10. It costs $94,500 for a 12-week regimen. Gilead's hepatitis C drug Sovaldi costs $1,000 a pill, or $84,000, for a 12-week regimen. However, Gilead argues that Harvoni can be a bargain considering that it costs $63,000 for an eight-week regimen and as many as 45% of patients may qualify for the shorter treatment duration.

Compliance to a treatment regimen may be higher with Harvoni than it is with Sovaldi. That's because Harvoni is the first single-pill hepatitis C treatment. Sovaldi requires intravenous treatment with interferon or ribavirin, which are known to have side effects including flu-like symptoms, experts say.

In addition, clinical trials for Harvoni found that over 94% to 99% of the patients treated with the drug had no detectable virus in their blood three months after treatment was ended. This compared with 82% to 90% nondetectable rates in clinical trials of Sovaldi plus interferon and ribavirin.

Despite claims of better price, fewer side effects and higher efficacy rates, it is unlikely states will make Harvoni their preferred hepatitis C drug over Sovaldi and will likely move forward covering both drugs simultaneously, experts say. One reason is that not everyone agrees with Gilead's assertion that Harvoni is more affordable.

“The older drugs used in combination with Sovaldi are very inexpensive to the Medicaid program due to large available rebates, so the cost of the interferon and the ribavirin is negligible,” a spokeswoman from the Minnesota Department of Human Services said. As a result, “the Sovaldi combination is still less expensive than the single-pill Harvoni regimen, at least for the Medicaid program.”

Another reason is that the drugs differ in terms of effectiveness for various strains of hepatitis C. There are six different genotypes of the virus. Harvoni is shown to be best for genotype 1, believed to be the most common strain, while Sovaldi is believed to be best for genotypes 2 and 3, according to Nancy Steinfurth, executive director of Hep C Connection, an advocacy and awareness organization.

As a result, Washington state will only cover Harvoni for those with genotype 1, a spokeswoman there said. Idaho is following a similar course of action, developing prior-authorization criteria that require a beneficiary to have documented proof that clinical need is not met by Sovaldi.

Medicaid agency spokespeople from Ohio, New Mexico and Texas say their agencies have yet to make decisions on what authorization criteria they'll use. None revealed a timeline to make a decision. Texas is also believed to be only state in the U.S. to not provide coverage in any fashion for Sovaldi, having yet to craft prior-authorization criteria for its use there.

Oregon has a unique waiver that allows it to not cover drugs, even if the manufacturer has an agreement with the federal Medicaid drug rebate program. It attempted to exercise this authority earlier this summer to not cover Sovaldi, but advocates were successful in stopping the state from taking the action. Instead Oregon created a prior-authorization criteria for the drug for the 10% of Medicaid beneficiaries in the state's fee-for-service program, and left it up to coordinated-care organizations that care for the other 90% to come up with their own prior-authorization policies for the drug. A similar course of action is expected for Harvoni, an Oregon Health Authority spokeswoman said.

For the vast majority of their Medicaid populations, states such as Hawaii and Pennsylvania are following Oregon's lead, leaving prior-authorization policies for Harvoni to their managed Medicaid providers. There are 37 states that in varying degrees use managed-care organizations to provide services to beneficiaries. Of those, 28 states include pharmacy benefits in their contracts.

Spokespeople from Iowa, Florida, Georgia, Minnesota, Montana, Nebraska, Nevada, South Dakota and Virginia, said they don't expect a prior-authorization policy to be developed for Harvoni until spring 2015 when their pharmacy and therapeutics committees or drug utilization review boards again convene to look into the drug's clinical benefit. Until then, some will allow access to the drug on a case-by-case basis, depending on documented medical necessity.

Alaska, Idaho, Tennessee and Oklahoma are now covering the drug with prior authorization, though the current pre-approval criteria may be later updated as they learn more about the drug, spokespeople from those states said.

In Mississippi, if Harvoni is administered in a physician's office, prior authorization is not required, said Erin Barham, deputy administrator for communications for Medicaid.

“Although this particular drug treatment for hepatitis C can be expensive, in a majority of cases it has a high potential of curing the disease if prescribed and taken correctly, resulting in a positive impact on beneficiaries and the state budget in the long run,” Barham said.

[Ekkiemom]

Hi everyone!
In Calif you need prior authorization. If you are eligible for Tx!  Depending if you have abstained from alcohol/drugs for 6 months, also if you have some cirrhosis and or liver stage and grade, and the usual jumping thru hoops.  
I have to say that it seems the higher the price of the drugs the more picky the insurance co.'s list of "who gets treated and who doesn't" gets increasingly longer.  Only those with F3-4 and higher seem to be the more immediate concern, which is how it should be, HOWEVER for some nonsensical reason they (insur co.'s) don't understand that treating them early with shorter Tx times would save them soooo much money, instead of wtg until they are much sicker or need transplants and pay for the yrs of "aftercare".
It's so hard to wrap your head around this "back assward" thinking. I'm jumpin off my soapbox now!
Anyway...hope all is well and......life is good!
Deb

[AWorriedMom]

As of January 4, 2015..... "New Jersey does not currently require any prior authorization for the new hep C drugs - but officials there are considering controls".