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Who Should Get Pricey Hepatitis C Drugs?

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More Hepatitis Patients Expected

No one expects all those infected with the hepatitis C virus to seek treatment: At present, most people with the virus don’t even know they have it, one of the reasons why fewer than 20 percent have sought treatment with the older regimens.

More patients are expected to be diagnosed, however, as health officials urge baby boomers to get tested. The blood-borne virus is spread mainly by intravenous drug use, although many people were unknowingly infected by poorly sterilized medical equipment and blood transfusions before widespread screening of the blood supply began in 1992. 

Policymakers say the cost of treating even half of those infected could raise premiums for everyone with private insurance.

In an earnings call last month, UnitedHealthcare, one of the nation's largest insurers, said it spent $100 million on hepatitis C treatments in the first quarter of the year, far more than it had expected.

Like many private insurers, United covers the drug broadly, following medical societies' recommendations, although some of its plans may charge patients higher co-payments for the drugs.

Another firm, MedImpact, which oversees pharmacy benefits for tens of thousands of people, saw its spending on hepatitis treatments nearly double this year to $37 million, when compared with the first quarter of 2013.

A Dilemma For Medicaid Programs

Because many of those infected are low-income, in prison or baby boomers, the spending is expected to fall hardest on taxpayer-funded health programs such as Medicaid and Medicare.

This “has the potential to throw a wrench into short-term state budgets,” said Matt Salo, executive director of the National Association of Medicaid Directors.

Medicaid programs, for the most part, are still setting coverage rules, relying on their own panels to review medical studies and recommendations from other groups. In Texas and elsewhere, Medicaid will not cover the drugs at all until those review panels issue guidance.

Other states have completed initial reviews. Florida, for example, placed Sovaldi on its preferred drug list, while Pennsylvania officials will seek public comment on draft rules requiring patients to show some liver damage, get a prescription from a specialist and have their treatment overseen by a case manager to qualify.

In an era of limited resources, the prices pose a particular dilemma for public programs.

“For the price of Sovaldi for one patient, we could provide health insurance through Medicaid for [up to] 26 people for an entire year,” said J. Mario Molina, chief executive of Molina Healthcare with Medicaid plans in 10 states.

“There’s no question it is a very efficacious drug. But it’s just who gets it and when.”

Molina is holding off on offering the drugs in many cases while it seeks answers from state officials about whether they will cover this year’s costs, which were not built into Molina’s contracts. Other Medicaid insurers are seeking similar assurances from state officials.

Fri, May 02 2014

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