NY State Moves to Remove Restrictions on HCV Drug Access by Private and Medicaid Insurers

According to a new report from the CDC, in 2014 one person died from hepatitis C (HCV) every 27 minutes, totaling 19,659 Americans in one year. The number of people dying from HCV surpassed the total number of deaths from 60 other infectious diseases combined, including HIV. Although lifesaving, the high cost of current treatments for HCV has led many health insurers to restrict access. The requirements and approval processes for HCV treatment varies by insurer. For example, criteria for Medicaid coverage vary among states based on the patient’s liver disease stage, HIV co-infection status, provider type and history of drug or alcohol use.

A recent investigation by New York Attorney General Eric Schneiderman has led to an agreement with seven commercial health insurers to eliminate these types of restrictions. After the agreement, all seven commercial insurers will cover treatment for chronic HCV “without requiring members to develop advanced disease, such as liver scarring and will not deny coverage because the member uses alcohol or drugs or because the authorizing physician is not a specialist.” Attorney General Schneiderman also recently settled a lawsuit filed against another private insurer to eliminate similar restrictions. By lifting these restrictions, the coverage policies will more closely align with the evidenced-based guidelines and recommendations from the American Association for the Study of Liver Disease (AASLD) and the Infectious Diseases Society of America (IDSA). The AASLD/IDSA recommendations “state that HCV treatment is indicated for all patients with chronic HCV (regardless of disease stage) because HCV therapy is curative, improves quality of life, slows liver disease progression and reduces the risk… for all-cause mortality.”

According to the Wall Street Journal, the New York State Department of Health reported that Medicaid insurers in the state will also update and expand their coverage policies. New York’s Medicaid program spent more than $400 million on HCV drugs from January to September of 2015. Currently, the New York Medicaid fee-for-service plans require patients to have a more advanced stage of liver fibrosis, a prescriber with experience and training, and patient readiness and adherence. However, the NY State Drug Review Board voted at their meeting on April 27th, 2016 to have NYS Medicaid fee-for-service plans cover certain HCV drugs before patients reach an advanced stages of illness. The New York State Health Commissioner has 30 days to respond to the recommendations, which do not immediately affect the state’s Medicaid managed care plans.