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.
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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.