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Who Should Get Pricey Hepatitis C Drugs?

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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.

Is There Harm In Waiting?

Waiting is not unusual for hepatitis patients. In the past, many chose to delay treatment because the available options were problematic. Older regimens were complex to administer, had to be taken for longer periods and were less effective. So there is pent-up demand for the new drugs, although some may still want to wait for interferon-free alternatives. 

Fri, May 02 2014

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