A study in the Annals of Internal Medicine (June 30, 2015) reveals the strategies used by state fee-for-service Medicaid programs to manage the utilization of newer, high-cost hepatitis C medications. Authors studied limitations for coverage of the drug Sovaldi (sofosbuvir).
The reason why the Medicaid restrictions noted in the study are significant is because, according to the authors, “the restrictions are not consistent with the FDA-approved labeling for sofosbuvir or evidence-based recommendations.” Federal law indicates Medicaid must cover drugs consistent with FDA labeling.
It’s a difficult proposition for states, however. The medication can cost $84,000 (wholesale acquisition price) or more for a single patient’s regimen, so Medicaid programs are attempting to prioritize patients for treatment.
The authors also say, “a growing body of evidence shows that there is no justification for systematically withholding HCV treatment” for individuals who use injected drugs, and yet, an overwhelming majority of states restrict access for that population.
Authors found that:
88% of States
Use alcohol/drug use or abstinence as criteria for coverage
2/3 of States
Require urine drug screening
Allow those who are currently in SUD treatment to bypass the abstinence requirement
Requires random urine drug screening during hepatitis C treatment
3/4 of States
Limit coverage to those patients who already have advanced liver disease
2/3 of States
Have restrictions on which type of clinician can prescribe the newer types of medication
1/4 of States
Have restrictions related to HIV
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