Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Private Payers News

Private Payers Deny Hepatitis C Drug Coverage to 52% of Members

Over half of private payer health plan beneficiaries were denied necessary hepatitis C drug coverage and prescriptions.

Over half of private plan beneficiaries were denied necessary hepatitis C drug coverage.

Source: Thinkstock

By Thomas Beaton

- Private payers denied Hepatitis C drug coverage to 52.4 percent of commercially insured beneficiaries from 2014 to 2017, according to new research from the Perelman School of Medicine at the University of Pennsylvania.

Hepatitis C drug access for public payer beneficiaries was also heavily restricted during the same three-year period. About 35 percent of Medicaid beneficiaries and 15 percent of Medicare beneficiaries were denied access to Hep C drugs.

Vincent Lo Re III, MD, MSCE, an associate professor of Infectious Disease and Epidemiology and senior author of the study, believes that both private and public payers experience significant financial challenges when reimbursing pharmacies for the cost of Hep C prescriptions. These financial challenges are likely to impede progress in combating hepatitis on a national scale, Lo Re and the team determined.

Direct-acting antiviral drugs (DAAs), once-a-day pills that have been available since 2014, can cost between $40,000 and $100,000 for a single course of treatment. The high costs of DAA treatments cause private and public payers to limit DAA treatments for Hep C patients with the most severe conditions.

“Despite the availability of these newer drugs and changes in restrictions in some areas, insurers continue to deny coverage at alarmingly high rates, particularly in the private sector,” Lo Re sai

“It warrants continued attention from a public health standpoint to have more transparency about the criteria for reimbursement of these drugs and fewer restrictions, particularly in private insurance and certainly to continue the push in public insurance, if we want to improve hepatitis C drug access across all states.”

Payers have been increasingly reluctant to pay for these expensive medications.  

Commercial payer denial rates for DAA drugs averaged 35 percent in the opening months of 2016 and spiked to 64 percent by the start of 2017.

In 2016, Medicare and Medicaid beneficiary denial rates for DAA drugs were at 10 and 31 percent, respectively. By 2017, 23 percent Medicare beneficiaries seeking DAA drugs were denied prescriptions and 41 percent of Medicaid members were denied DAA coverage.

The authors found that denial rates are increasing within public and private insurance sectors and may continue to increase if payers can’t efficiently manage costs related to DAA prescriptions.

Increasing rates of DAA denials across all beneficiary groups presents significant public health concerns for the future, the team cautioned.

Data from the National Academies of Science, Engineering, and Medicine shows that 260,000 beneficiaries with chronic hepatitis-based conditions need to be treated each year in order to eliminate the Hep C virus by 2030.

Lo Re and the American Association for the Study of Liver Diseases and Infectious Diseases Society of America suggests both private and public payers need to expand access to DAA to the best of their ability.

Payers that promote DAA access could create long-term improvements for US public health and limit the development of other chronic conditions, Lo Re concluded.

“From a clinical standpoint, patients with chronic hepatitis C who are denied therapy can have continued progression of their liver fibrosis and remain at risk for the development of liver complications, like cirrhosis, hepatic decompensation, and liver cancer,” Lo Re said.

“In addition, chronic hepatitis C promotes not only liver inflammation, but systemic inflammation, which can lead to adverse consequences on organ systems outside of the liver, such as bone, cardiovascular, and kidney disease. Further, untreated patients can continue to transmit infection to others.”

“Eliminating hepatitis C in the U.S. is a feasible goal, but that’s going to be hard to achieve if payers are not reimbursing for the treatment,” Lo Ree added.


Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...