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Medicaid Patients Denied Harvoni Treatment

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Indianapolis, INAlthough most of the news regarding denied Harvoni insurance claims and resulting lawsuits involves private insurance providers, it appears Medicaid is also denying patients necessary Harvoni treatment. Patients allege Medicaid and other insurance providers are playing with their lives by deeming the hepatitis C treatment not medically necessary.

NPR (12/27/15) reports that Sarah Jackson was prescribed Harvoni treatment for her hepatitis C, but Indiana’s Medicaid program refused to pay for it. Harvoni costs around $95,000 for a 12-week course - incentive for insurance providers to deny coverage - but it has a more than a 90 percent success rate. That’s a high success rate for a condition that can cause serious liver problems and even death.

According to NPR, however, at least 34 states will not pay for Harvoni treatment unless a patient already has liver damage, a consequence of hepatitis C. A study published in the Annals of Internal Medicine (6/30/15) found that 42 states including the District of Columbia have public information about their Medicaid reimbursement criteria for sofosbuvir (the generic name for Sovaldi, a similar drug to Harvoni). Of those, 74 percent limit access to patients who have advanced liver disease. Nine states have unknown criteria. Nevada is the only state in which it is public information that there is no prior authorization required for sofosbuvir.

In other words, patients who have a disease that could cause severe liver damage have to show enough liver damage to warrant treatment before they are given access to the treatment that could prevent liver damage in the first place.

The US Senate Finance Committee has weighed in, criticizing Gilead Sciences - maker of Sovaldi and Harvoni - for basing the price of the drugs on maximizing revenue.

Sovaldi costs $1,000 per pill or $84,000 for a full treatment. According to a letter from the committee, in the 18 months following Sovaldi’s approval on the market, Medicare spent an estimated $8.2 billion on Sovaldi and Harvoni.

“Gilead pursued a calculated scheme for pricing and marketing its Hepatitis C drug based on one primary goal, maximizing revenue, regardless of the human consequences,” Senator Ron Wyden (D-Ore) said. “Gilead knew these prices would put treatment out of the reach of millions and cause extraordinary problems for Medicare and Medicaid, but still the company went ahead.”

For now, patients are left to fight with Medicaid and other insurance providers to try to get the treatment they desperately need, while insurance providers continue to demand evidence of sufficient liver damage before they approve treatment. According to NPR, Sarah Jackson has filed a lawsuit with the help of the ACLU of Indiana, arguing that Medicaid is legally obligated to pay for any drug a doctor deems medically necessary.


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Posted by

I have been infected with the hepatitis c geno type 1a, I was infected while in prison in Colorado in 2013. Since my release in 2014 I have been seeing a doctor for this condition. Still to this day my doctor says I am being denied although my liver is in fibrosis stage already. I feel sick everyday to my stomach. This illness is killing me slowly and am not sure if Medicaid will ever cover the medication harvoni. Any advice or help would be greatly appreciated.

Posted by

My fiance has been denied treatment for his HepC. He had a liver biopsy and it showed level 1-2 amounts of hepatic changes and fibrosis and I believe they said it has to be level 4 or more.
I am in disbelief that he is expected to just let this disease progress.

Posted by

My wife was diagnosed with hep c from a blood transfusion as a baby from UNM Hospital. Her Medicaid was denied because she was "not sick enough". She has never used a needle and doesn't drink alcohol. Please help her get the treatment she deserves.


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