Is A Cure Worth $84,000?
Another part of Medicare's problem is that new hep-C medications are among the priciest of any drugs. One called Sovaldi, federally approved last December, costs $1,000 a pill - or $84,000 for a typical 12-week treatment course. The other recently approved drug, Olysio, costs around $66,000. Others in the pipeline are expected to be similarly expensive.
"People were very shocked about the price because it hit a psychological barrier in terms of 'this is too expensive,'" Graham says.
She has a patient like Walter Bianco - a 65-year-old woman whose severe liver damage puts her on the edge of liver failure.
Graham believes her patient's best chance at cure lies in the use of both Sovaldi and Olysio. "We have about 160 people who were studied in a clinical trial called COSMOS that showed a very high cure rate - 90 to 100 percent - for even the most difficult-to-treat patients with this combination," she says.
But, as in Bianco's case, the Medicare's drug-benefit contractor that covers this patient has refused to approve payment.
The apparent reason is that the Food and Drug Administration has not yet approved use of the two drugs in combination. (On May 7, Olysio's maker, Janssen Therapeutics, asked the agency for such approval.)
But Graham notes that in the early days of successful antiviral drug treatment for HIV, payers allowed doctors to "mix and match" medications in "off-label" or unapproved combinations as they thought best.
"Medicare has been slower to adopt off-label combinations than most of the other insurance plans," Graham says.
Medicare officials wouldn't comment on coverage of new hep-C drugs. A spokesman wrote in an email that the federal program turns such decisions over to private insurers that administer its drug plan, called Medicare Part D.
However, advocates say Medicare officials are well aware of the program's looming exposure to the enormous costs of treating hep-C. Some say it could run in the tens or hundreds of billions of dollars, though it's not clear over what period of time.
Fri, May 09 2014