Private insurers deny drug coverage for half of hepatitis C patients

Hepatitis C rates in Pennsylvania have skyrocketed in recent years, due in large part to a rise in injected-drug use. But a new study by University of Pennsylvania researchers shows that many patients aren’t able to take drugs that would cure the disease because their insurers won’t pay for it.

In a national survey of more than 9,000 prescriptions for “direct-acting antiviral drugs” — once-a-day pills with a 95 percent cure rate — researchers found that 35 percent of those requests were denied. Private insurers denied half the requests for the pills, marketed under various names including Harvoni and Mavyret.

The pills are expensive, costing anywhere from $35,000 to $95,000 for a treatment course that lasts eight to 12 weeks. The high price tag has led many insurers — public and private — to cover the drugs only for the sickest patients and those who aren’t using drugs or alcohol.

Vincent Lo Re, associate professor of infectious disease and epidemiology at Penn and a senior author of the study, said private insurers worry about bursting their health care budgets by covering costly drugs. But he pointed to cost-effectiveness studies showing that, although the upfront cost is high, the lifetime cost of these drugs is actually less.

“Hepatitis C causes not just liver inflammation, but also systemic inflammation around the body,” he said. Failing to treat the disease can lead to other health issues including metabolic bone disease, neuropsychiatric disease, cardiovascular disease, and kidney disease, all of which lead to high downstream medical costs.

He also said it’s bad policy to wait to treat hepatitis C until it is more advanced.

“Imagine that your family member has cancer,” he said. “And the insurer is telling you, ‘You know, we’re going to hold off treatment until the disease is more advanced and metastatic.’

“You would sort of scratch your head and say, ‘Well, how does that make sense? Isn’t it going to be harder to treat?’”

Previous treatment for hepatitis C included a combination of interferon injections and a pill, but the treatment had side effects similar to those of chemotherapy and only cured the disease in about half the patients who followed the protocol. The new treatments have become the standard of care.

Pennsylvania loosened its Medicaid restrictions in January and now covers the new wave of hepatitis C drugs for all patients. The state’s program formerly covered only the drugs for patients with signs of advanced liver disease.

However, according to the study, private insurers haven’t loosened their restrictions. In fact, they have actually increased the rate at which they deny prescriptions for the drugs since the researchers began tracking the issue in 2014 — up from 10 percent to 52 percent. In the most recent study, the rate also rose for each quarter of the 16 months the researchers studied.

Researchers did not have data from specific private insurers, so they could not assess denial rates by a specific plan.

For their part, private insurers say their approach is working. Independence Blue Cross, the region’s largest insurer, pointed to a 90 percent approval rating for hepatitis C treatment in the first quarter 2018.

“Coverage of hepatitis C is available to Independence Blue Cross members who meet our medical necessity criteria, which are consistent with American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines,” said Richard L. Snyder, senior vice president and chief medical officer at Independence Blue Cross, in a statement. “For our members seeking authorization for direct-acting antiviral therapy for hepatitis C, we follow clinical policies that outline what is considered medically necessary.”

Lo Re said stakeholders can do more and need to come together to figure out how to eradicate the disease.

“There’s not a lot of infectious diseases that we can eliminate, that we have good therapies for,” he said. “This is one of them.”

This disclosure: Independence Blue Cross supports WHYY.