How insurance providers deny hepatitis C patients lifesaving drugs - Doctors say up to 80 percent of patients are denied expensive but effective drugs like Harvoni

Amber Rojas was almost eight months pregnant when she learned she had hepatitis C. After her daughter was born on Dec. 23, 2014, Rojas had hoped to start treatment with a newly approved, highly effective drug called Harvoni.

After filing for prior authorization and waiting for months, the 34-year old mother received an unwelcome letter on August 27, 2015 — her treatment request had been denied because her liver was still too healthy. Rojas said that even though she felt very sick with flu-like symptoms, her insurance provider deemed her “not sick enough to qualify.”

Rojas is one of an estimated 3.2 million Americans with hepatitis C, an infection that attacks the liver. In the United States, hepatitis C kills more people every year than HIV. Drugs like Harvoni promise to cure more than 90 percent of patients, yet many insurance providers authorize treatment only if a patient has extensive liver damage, or a fibrosis score of 3 or 4.

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As insurers limit access to hep C drugs, patients and doctors bristle

Doctors are finding themselves in tense situations as they try to prescribe new hepatitis C drugs to patients eager for a cure while health plans limit coverage to manage the costs of the medications.

Many health insurers have established prior-authorization criteria generally limiting access to the drugs to patients whose disease has progressed to at least Stage 3 fibrosis (just before the onset of liver cirrhosis).

The sticker prices of a course of treatment of the drugs range as high as $95,000. To mitigate the burden, major health insurers and pharmacy benefit management companies have entered special pricing agreements with Gilead for its new hepatitis C drugs Harvoni and Sovaldi or AbbVie for its competing drug Viekira Pak.

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USA-Lack of Insurance Bars Some from Hepatitis C Treatment

Survey data from 2001 to 2010 show that lack of insurance kept some people with hepatitis C virus from getting treatment.

Recently, more effective and well-tolerated drugs have been developed to treat hepatitis C, removing many of the discouraging side effects of older drugs. The infection is curable and transmission can be prevented, researchers write in the American Journal of Gastroenterology.

But for the more than three million people in the U.S. who have chronic liver disease from hepatitis C, there are still two important barriers to getting treatment, said lead author Dr. Ivo Ditah from the Mayo Clinic in Rochester, Minnesota.

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Harvard Pilgrim negotiates discount on pricey hepatitis drug

Harvard Pilgrim Health Care has become the first regional health insurer to negotiate a discount on a costly new hepatitis C drug regimen that cures more than 90 percent of people with the virus but inflicts steep financial losses on payers.

Under a one-year contract with Gilead Sciences Inc., maker of the two-drug Harvoni treatment for the liver-ravaging disease, Wellesley-based Harvard Pilgrim expects to save about $10 million on reimbursements to doctors who treat hepatitis C patients. The insurer didn’t disclose how much it will pay for the drug after a rebate from Gilead.

Harvard Pilgrim followed the lead of national pharmacy benefit managers such as CVS/Caremark and Express Scripts, which buy prescription drugs in bulk. Taking advantage of a rival hepatitis C drug combination from AbbVie Inc., those companies recently bargained with both drug makers to secure rebates.

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UnitedHealth Said to Pick Gilead’s Harvoni as Hepatitis C Drug

(Bloomberg) -- UnitedHealth Group Inc., the biggest U.S. health insurer by sales, picked Gilead Sciences Inc.’s Harvoni as its preferred hepatitis C treatment, according to a person familiar with the matter.

The decision applies to UnitedHealth’s fully insured commercial customers, as well as to Medicaid and Medicare members. The Minnetonka, Minnesota-based insurer has about 45 million U.S. health-plan customers, though not all follow the company’s drug picks.

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Aetna backs Gilead's hepatitis C treatment, gets discount

(Reuters) - Aetna Inc, the third-largest U.S. health insurer, said it negotiated a discount with Gilead Sciences Inc for its hepatitis C treatment and will offer it as the preferred choice to nearly 11 million commercial customers.

Aetna, which posted an updated coverage policy on its website on Friday, said it believes the price it received for Gilead's Sovaldi, and a newer combination treatment called Harvoni, is "competitive with other recently announced agreements for this class of therapy." It would not detail the size of the discount.

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Humana opts for Gilead in hepatitis C drug battle

Humana acknowledged late Tuesday it has an exclusive deal to offer Gilead Sciences' hepatitis C drugs to its members.

Humana CEO Bruce Broussard told investors in a breakout session that it has a pricing arrangement with Gilead, but he did not disclose what kind of discount the health insurer received for the pricey drugs. High specialty drug costs were part of the reason why Humana's profit was lower in the third quarter.

The company's announcement is the latest in a string of bargaining battles between health insurers and pharmacy benefits managers and pharmaceutical companies. Anthem was the first payer to announce an agreement, saying last week it would use Gilead's drugs for its hepatitis C patients. Gilead makes Sovaldi and Harvoni, which cost $84,000 and $94,500 respectively for the usual 12 weeks of treatment.

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UPDATE: Gilead (GILD), AbbVie (ABBV) Hep. C Drugs Both Given Prefered Status at Prime

Gilead (Nasdaq: GILD) and AbbVie (NYSE: ABBV) Hep. C drugs were both given prefered status at Prime. A press release is below.

People with Hepatitis C who are served by pharmacy benefit manager Prime Therapeutics LLC (Prime) will now have greater support for the treatment recommended by their physician. This is a result of new agreements between Prime and pharmaceutical companies Gilead Sciences and AbbVie. Beginning immediately, the agreements place both Gilead's Harvoni® and AbbVie's Viekira Pak® on Prime's preferred drug list (formulary), meaning members can more easily get the medicine they need to feel better and live well.

"There has been a substantial reduction in the net price of both of these drugs just in the past few weeks, so sometimes it pays not to go first," said Peter Wickersham, senior vice president of Integrated Care and Specialty, Prime. "It was clear that neither Gilead nor AbbVie wanted to be left off our formulary and the result proved to be significantly better than taking an exclusive position."

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CVS will cover Gilead hepatitis C treatment over new AbbVie drug

CVS Health Corp., one of the largest U.S. managers of drug benefits, said it would give the hepatitis C treatment from Gilead Sciences Inc. preferred status and cover a new competing treatment from AbbVie Inc. only as an exception, CNBC reported on Monday.

Shares in Gilead rose nearly 3 percent after the report that CVS would favor the treatment, which can cost about $84,000, or $1,000 per pill. Its cost has spurred a national debate about whether drug prices had soared too high.

Two weeks ago, the nation's largest drug benefits manager, north St. Louis County-based Express Scripts Holding Co., said it would cover a competing, newly approved treatment from AbbVie rather than Gilead, and Gilead shares fell sharply.

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