July 1, 2015
HCV Treatment Coverage Restrictions Among Medicaid Programs
Atif Zaman, MD, MPH reviewing Barua S et al. Ann Intern Med 2015 Jun 30. Canary LA et al. Ann Intern Med 2015 Jun 30. McCance-Katz EF and Valdiserri RO. Ann Intern Med 2015 Jun 30.
Reimbursement eligibility criteria vary widely across states.The new hepatitis C virus (HCV) treatment regimens are safe and highly effective but costly. Because of their high price, many insurers, including Medicaid, have implemented coverage restrictions and prior-authorization requirements.
To systematically evaluate state Medicaid polices for HCV treatment with sofosbuvir in the U.S., investigators searched state Medicaid websites for reimbursement criteria data from the 50 states and the District of Columbia. Data were limited to Medicaid fee-for-service beneficiaries only.
Reimbursement criteria were publicly available in 42 states, including D.C. (82%). Nine states provided no information regarding their criteria, and Nevada did not have reimbursement criteria. Among the 42 programs with restrictions, results were as follows:
Eighty-one percent restrict coverage based on fibrosis stage (stage 4 only, 10%; stage 3–4 only, 64%; stages <3 covered, 7%).
Sixty-nine percent restrict coverage based on prescriber type; half limit prescribing to specialists, and the other half require consultation with a specialist.
Eighty-eight percent include drug and alcohol use in eligibility criteria; 19% require evaluation of substance/alcohol abuse, and 50% require a period of abstinence (6 months, most frequently) prior to starting HCV treatment regardless of abuse history.
Editorialists argue against abstinence restrictions, citing evidence of similarly successful HCV treatment outcomes in substance-use and non–substance-use populations alike. Moreover, they argue that from a public health standpoint, treating HCV infection in people receiving substance use treatment would decrease the HCV risk pool and reduce the risk for HCV infection in the general population.
Comment
These findings show wide variability among state Medicaid programs in eligibility criteria for HCV treatment reimbursement. These policies seem to be inconsistent with national recommendations from professional societies (Infectious Diseases Society of America and the American Association for the Study of Liver Diseases) and, moreover, may violate federal Medicaid laws. The restrictions are not surprising given the financial burden these costly regimens have placed on the Medicaid system. However, as the authors note, policies that are intended to prioritize treatment for patients with the most immediate need should be based on clinical criteria and medical evidence and then applied consistently across all Medicaid programs.
Editor Disclosures at Time of Publication
Disclosures for Atif Zaman, MD, MPH at time of publication Nothing to disclose
Citation(s):
Barua S et al. Restrictions for Medicaid reimbursement of sofosbuvir for the treatment of hepatitis C virus infection in the United States. Ann Intern Med 2015 Jun 30. (Δεν είναι ορατοί οι σύνδεσμοι (links).
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Canary LA et al. Limited access to new hepatitis C virus treatment under state Medicaid programs. Ann Intern Med 2015 Jun 30. (Δεν είναι ορατοί οι σύνδεσμοι (links).
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McCance-Katz EF and Valdiserri RO.Hepatitis C virus treatment and injection drug users: It is time to separate fact from fiction. Ann Intern Med 2015 Jun 30. (Δεν είναι ορατοί οι σύνδεσμοι (links).
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