Does your state's Medicaid program cover the cost of Sovaldi or Olysio?

[LDVZ]

I'm curious to hear whether the costs of the new drugs Sovaldi or Olysio are covered by your states Medicaid program?

State officials at Medicaid programs in Louisiana, California, Michigan and Florida said in interviews that they will only approve the use of Gilead’s Sovaldi on a case-by-case basis while they study how best to address the drug’s cost going forward.

In Colorado, officials advised doctors in a Feb. 19 letter that “new therapies for hepatitis C will not be approved” until the state can negotiate a price with Gilead.

With the suggest price tag of 84,000 dollars for a single round of treatment it seems many state Medicaid programs are bulking at the idea of making a formulary inclusion of this drug due to its enormous price tag.

I have read that if everyone in the U.S. with hepatitis C were treated with Sovaldi at its list price, it would cost $227 billion compared with the estimated $260 billion spent a year in the country for all drugs.

I'd like to hear from others that are on Medicaid or know someone that is and what their access to the new Direct-Acting Antiviral medications for Hepatitis C is. Does your state cover the cost and if so what are the stipulations for coverage. Thanks  

[Sovaldi13Newbie]

Hi, I have medi/medi, Medicare and Medical, and when I first applied, I was denied. But I found out who the appeal board was (there is always an appeal board) and I asked them if I could write my own letter to go along with their appeal, they said yes. I write a good letter. In the meantime, I went to Sovaldi themselves and they said that I qualified for their patient care program so they would be giving it to me for a very small co-pay. Then my appeal came through! So, of course, Sovaldi backed out and said let your drug insurance program pay for it. (Duh) I knew they'd do that. So now I'm not even on my second week (that will be this Wednesday) and for the past 12 years my Liver Function tests have always been hovering around the high 30, 40, 50s. Today I got a test (I won't be getting my viral load test for another few weeks) and my Liver Function Tests are 17 and 18!!!!! I'm over the moon!!!!! I hope this helps. These new drugs are miracle workers!

[rockymoe]

Maine is only paying for those that have treated before and the ones. Very sick from Hep C. Others have to go on the interferon based treatments.
I am lucky my regular insurance denied it the first time but approved the appeal. This is my 9th treatment and I can never use interferon again, it almost killed me last time. It is a very expensive treatment. Olysio and Savadi together! This one better work because I am really tired of fighting this disease. It is especially ha rd when you have sides but look like you are doing so well. I am exhausted and have headaches and I don't feel like doing a lot and I know people are probably thinking she is lazy! Oh well I have fought it long enough to let peoples opinions fly right over my head!

[LDVZ]

That was very helpful, thank you Klonnny55. I hope you were able to rid yourself of the HCV virus. Sincerely, Linda from Oregon.

[klonny55]

Hi LD,

I have (had?) genotype 2 and was diagnosed in April of 2013. A biopsy in June 2103 showed F2-3 fibrosis. I was covered for 12 weeks of Sovaldi and Ribavirin through my state's (Vermont) medicaid expansion program. My prescription was written on January 6 of this year. It was initially denied but then approved after my doctor's office went to bat for me. Soon after my approval VT medicaid stopped all approvals of Sovaldi as the controversy around it's price tag escalated. I was very lucky to have been approved, it was all in the timing.

What I understand in reading about this in various places online is that some states are approving the meds but only for those needing transplants or with cirrhosis and ESLD. I would not have been approved under these guidelines.

As far as your question about the process for those on medicaid: Your doctor writes a prescription for the meds and they are submitted to medicaid for prior authorization. There is most likely a denial. Then an appeal is filed by your doctor. At this point your doctor will need to make the case for why you need the drugs now. If your situation is compelling enough you may get approved, with the emphasis on MAY. The only way to know is to go through the process and fight for approval. Be your own advocate, work with your doctor to make sure everything possible is being done to make your case.

Hope this helps, Best of Luck!

[LDVZ]

I should correct that, low-income, there are more low-income sufferers of HCV than not. That being the case, you'd think there would be a lot of buzz regarding the availability or non-availability of these drugs for end-stage, low-income HCV infected individuals.  

[LDVZ]

Interesting, not a one person on Medicaid that needs these meds. Quite surprising being that it is projected that the majority of HCV sufferers are likely to be impoverished.

[LDVZ]

That would be wonderful. I think it will help others in a similar position to get a bigger picture of what sort of process is involved in order to receive the new drugs if one is insured with Medicaid.

[truredhead]

I am on medicare from disability, so I have medicaid/medicare. I have an appt monday with my doc and will find out more about the drugs and if they are covered. I already had an endoscopy and a tumor marker test for this doc and they both came back fine so we will see what he says now. I do not know how quick it is or how they ask the medicaid and medicare to cover the drugs. I will let you know Monday what I find out. I am hoping they cover the treatment too! He knows what insurance or lack there of that I have so I think he knows it can be covered or he would have not started those tests.

[LDVZ]

Yes, it sounds like your husband was given what is called "Step Therapy." In order to save costs state's Medicaid programs seem to require that a patient first take less expensive/ "conventional" treatments before they can even be eligible for the newer Direct-Acting Antivirals like Sovaldi and Olysio.

In most cases it appears, state Medicaid programs will not allow the use of Sovaldi or Olysio except in very severe cases, i.e. end-stage liver disease or severe fibrosis. And in some cases only after the patient has complied with what is known as "Step Therapy."

Unfortunately, Step Therapy comes with some risks, as the older medicines called "protease inhibitors" in many cases must be used in concert with Ribavirin and Interferon also known as Pegasys. Unfortunately, sever side effects are quite common with these older drugs and for many they have had to cease treatment because of the severe side effects encountered while taking it.

I know for a fact that the state of California is currently negotiating the price of Gilead's Sovaldi. It's worrisome to the state of California because it has a large population and with that quite a few HCV infected citizens. The state's Medicaid program is already under financial strain, the asking price for Sovaldi is a game changer in that no other drug has shredded earnings profits like Solvadi is now. Private insurance companies as well as the governments two largest health care programs are feeling the sticker shock.

I can't recommend anything in terms of medical referral. I would recommend you do as much homework about any drug or combination of drugs your husband might take in the future. I think it would be wise to stay abreast of your state's current Medicaid pricing management program and contact your local Senator or representatives and let them know the predicament your husband is in.

There may come a point, if it already hasn't occurred that the state of California and its Medicaid program will pay for the newer DAAs Sovaldi and/or Olysio but only in the most severest of cases like sever fibrosis or end-stage liver disease.

Thank you for sharing your story with me.  

[Lilkcjames]

Hello. My husband just saw his hepatologist this week in Sacramento, Ca. He initially was started on PegaSys which two weeks in resulted in horrible mental changes, extreme confusion and a stroke. We have bee axiously awaiting this appointment to start him on the "new pill' Sovaldi. He was told a year ago that it was imperative that he get on treatments ASAP. Now doctor states, well each pill is $1000 and there are so many people in California needing this medicine - even though your liver enzymes are very high - I don't think it would hurt for you to wait until October when Ledipsavir is approved. He has Medicaid. What do you think???