Doc, in­surer ten­sions grow over hep C drug cov­er­age

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Physi­cians face tough predica­ments in at­tempt­ing to pre­scribe highly ef­fec­tive new hep­ati­tis C drugs for their pa­tients while health plans strive to curb the high costs of those med­i­ca­tions.

Many in­sur­ers have set cri­te­ria gen­er­ally lim­it­ing ac­cess to the break­through drugs to those hep­ati­tis C pa­tients whose dis­ease has pro­gressed to at least Stage 3 fi­bro­sis, just be­fore on­set of cir­rho­sis of the liver. But some doc­tors say in­fected pa­tients at any stage of the dis­ease should have ac­cess to the drugs, which have cure rates ex­ceed­ing 95%.

Last week, a Los An­ge­les woman sued An­them Blue Cross for deny­ing cov­er­age for Gilead Sciences’ drug Har­voni, even though her physi­cian rec­om­mended she take it. The Food and Drug Ad­min­is­tra­tion ap­proved Har­voni in Oc­to­ber 2014. With­out in­sur­ance cov­er­age for the drug, she would have to pay $95,000 for a 12-week course of treat­ment, she al­leges in the law­suit.

Dean Sal­vani, 59, of Bell­more, N.Y., said he’s twice been de­nied cov­er­age for Har­voni by Unit­edHealth­care. “There’s fi­nally a cure, but I can’t get it,” said Sal­vani, who suf­fers se­vere mus­cle and joint pain from the dis­ease.

Unit­edHealth­care de­nial let­ters re­viewed by Mod­ern Health­care said Sal­vani’s cov­er­age was de­nied be­cause he hadn’t reached Stage 3 fi­bro­sis.

United spokesman Tyler Ma­son said the com­pany be­lieves its cov­er­age poli­cies “are con­sis­tent with clin­i­cal ev­i­dence to pri­or­i­tize treat­ment based upon the pro­gres­sion of the dis­ease, i.e., treat­ing the sick­est pa­tients first. Mr. Sal­vani’s cur­rent con­di­tion may not meet that cri­te­ria.” He cited data from the Cen­ters for Dis­ease Con­trol and Pre­ven­tion show­ing that for ev­ery 100 peo­ple in­fected with hep­ati­tis C, only five to 20 will de­velop cir­rho­sis over a pe­riod of 20 to 30 years.

Gilead Sciences’ CEO John Martin said dur­ing an earn­ings call ear­lier this year that his com­pany thinks a sig­nif­i­cant num­ber of pre­scrip­tions are not be­ing filled be­cause of health plan re­stric­tions. The com­pany found that in 56% of cases in which a provider sought to pre­scribe one of Gilead’s hep­ati­tis C treat­ments in the first three months of this year, pa­tients scored be­tween a zero and Stage 2 on the fi­bro­sis scale.

But some ex­perts ques­tion in­sur­ers’ rules bar­ring cov­er­age for mod­er­ate and ad­vanced fi­bro­sis. Clin­i­cians “know sur­pris­ingly lit­tle about the health im­pacts of de­lay­ing treat­ment,” David Rein, prin­ci­pal re­search sci­en­tist with NORC, an in­de­pen­dent re­search or­ga­ni­za­tion at the Uni­ver­sity of Chicago, wrote in the jour­nal Clin­i­cal In­fec­tious Dis­eases in March.

Martin

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