Insurer expands hep C drug coverage

September 16, 2016

Nationwide class action suit spurs new coverage decision for hepatitis C medications.

Many patients will experience expanded access to hepatitis C drugs as a result of a class action settlement estimated at more than $300 million.

Maxwell

“United HealthCare placed restrictions on the use of Harvoni, a very expensive medication used to cure hepatitis C,” according to Terri Maxwell, PhD, APRN, vice president, clinical education, Enclara Pharmacia. “United HealthCare's restrictions were deemed too restrictive by the courts-patients had to wait until their condition deteriorated and/or fully abstain from alcohol and drugs before having access to the drug. The courts awarded the plaintiffs a settlement of $300 million dollars and agreed to expand their coverage of hepatitis C drugs.” 

Hepatitis C is a global health epidemic affecting hundreds of millions of people worldwide. As complications from the disease, such as cirrhosis, continue to become more frequent, treatment becomes increasingly important, according to experts.

This is the second court case, following a similar settlement a few months ago against Blue Cross Blue Shield in Florida, that has forced health insurers to pay for hepatitis C medications regardless of stage or life choices, i.e., alcohol use, according to Julie Rubin, PharmD, BCPS, director of clinical services, CompleteRx.

However, there is still physician oversight in determining candidates for the drug, adds Maxwell.

Rubin

“By lifting these restrictions, the courts have set a precedent whereby anyone who has been diagnosed with hepatitis C will be eligible for treatment regardless of whether they intend to be compliant or avoid negative behaviors,” Rubin says. “Assuming the list price for Harvoni is $63,000 for an eight-week course of therapy and the settlement applies to approximately 5,000 people, the potential value to class members is more than $300 million. In addition, the healthcare industry stands to realize billions of dollars in cost savings as treating this expanded universe of patients may help prevent costs associated with disease progression, future liver transplantation, and long-term complications from the disease.”  

Maxwell agrees. “More people will now have access to hepatitis C drugs that are capable of curing the disease,” she says. “This puts insurers on alert that they cannot use overly restrictive clinical criteria as a means to reduce access to very expensive therapies.”

Historically, treatment has been a double-edged sword as it has been expensive in the short term, but led to long-term cost-savings by preventing hepatitis C complications, Rubin says.

“Now, as a result of this ruling, hospitals may also be able to save on the front end as it will be more difficult for insurers to restrict reimbursements for hepatitis C medications,” Rubin says. “This change-combined with new medications coming to market with exceedingly high cure rates-will eventually lead to decreased admissions due to hepatitis C complications, as well as significant hospital savings.”

Furthermore, UnitedHealth also agreed to create a fund of $500,000 to allow former policyholders to buy insurance again, whether it's from UnitedHealth or another insurer.