Need Hep C Treatment Coverage? Here’s Help!

An HCV specialist often has a dedicated staff to navigate the complex maze of prior authorizations and other hurdles to accessing meds. But it’s getting easier for your primary-care doctor to help, too. “The American Association for the Study of Liver Diseases created a simplified one-page set of guidelines for primary-care doctors to treat HCV,” says Paul J Pockros, M.D., director of clinical research at Scripps Clinic in San Diego. No matter who you see, treatment coverage will vary depending on your insurance type. Here’s what you need to know:

When these drugs were initially approved, most private insurance plans wouldn’t pay for the medication unless patients were very sick, nor would they cover patients who used drugs or alcohol. Now, companies have largely lifted those discriminatory practices. “The challenges for coverage differ by state, but generally, people with private health insurance today are able to see a clinician to have the required bloodwork and liver staging done,” says Lauren Canary, director of the National Viral Hepatitis Roundtable (NVHR) in Washington, DC.

About 12% of Americans do not have any health insurance, and 23% lack adequate coverage. If that’s you, you may struggle to afford the sky-high price of HCV drugs out-of-pocket. Often, it’s cheaper to pay the monthly premiums for an insurance plan that covers HCV medication than it is to pay for drugs directly. Your first step is likely to enroll in a healthcare exchange, or, if you’re eligible, a state Medicaid program. You can also seek care at a free or low-cost clinic using this government website.

If you’re uninsured or underinsured, you may be eligible to receive financial help from one of the companies that manufactures hepatitis C medication. Each of these companies offers some sort of financial assistance program for people without insurance. Meanwhile, various non-profit organizations may be able to help you afford expensive co-pays, and pharmaceutical companies may also offer their own co-pay assistance programs. A comprehensive list of available patient assistance programs can be found on the NVHR website.

For patients covered by Medicaid, the ease of accessing HCV treatment depends greatly on where you live, with some states only covering certain patients. “Even though rationing practices are illegal, we still see treatment restrictions in more than half of the state Medicaid programs in the U.S.,” says Canary. Urge your physicians to seek authorization, even if you think you will be denied, and if you are denied, reach out to your state hepatitis coalition and advocacy groups like NVHR for advice. And if nothing else, “you may want to consider legal recourse,” says Canary.

If you’re covered by Medicare, the government insurance program for people older than 65, it’s likely you’ll have a relatively easy time getting tested, treated, and cured of HCV. The reason: HCV is a disease that gets worse over time, leading to more hospitalizations the longer you wait to get treated. Since people who are enrolled in Medicare are enrolled for the rest of their lives, treatment for HCV now avoids the even-higher costs for the program in treating liver injury, cancer, or possibly transplants down the line.

If your insurer is balking at paying, urge your physician to follow through on prior authorization requirements, even if you know you will be denied. “It helps to have a denial letter in your hands,” says Phil Waters, staff attorney at the Center for Health Law and Policy Innovation at Harvard Law School in Cambridge, MA. “Keep all your records together so that if you appeal the decision, you have everything you need.” The good news: If you do take legal action, there is a track record of successful outcomes in many states when patients have sued for HCV treatment coverage.

Without access to affordable coverage, people are paying hundreds of dollars to import cheaper generic equivalents from overseas. These online “Buyer's Clubs” are proliferating in the United States, but this option is risky and not advisable, cautions Canary. Scams are prevalent in the online drug market, and there’s no way to guarantee the authenticity of what you’re buying. “Importing international treatments is particularly concerning because people cannot guarantee the quality of the medications they are receiving,” she says.

With a cure in hand, worldwide elimination of HCV is possible. But according to the most recent data, only 12 countries in the world were on track to eliminate HCV, according to the World Health Organization. With sporadic testing and low treatment, the United States is not among them. Instead, ongoing battles over insurance coverage and drug cost mean only about one in five people living with HCV in the U.S. has been treated. If you are living with HCV, find a doctor who will fight for your health, and don’t give up. A cure is out there.