Insurance Companies Will Only Pay for Expensive Hep C Drugs If Patients Are Really Sick

By John Lavitt 10/29/14

Insurance companies don't seem to care about stopping hepatitis C in the early stages and preventing patients from developing permanent liver damage.

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Given the high cost of Gilead’s hepatitis C treatment drugs Sovaldi and Harvoni, insurance companies are on the verge of offering to pay for the ultra-treatment if a patient is ultra-sick. Such a financial decision to save their profits is bad news for the estimated 3.2 million Americans infected with the HCV virus. If a patient is not treated during the early stages of the viral infection, it is likely the chronic disease will permanently damage their livers.

The many patients whose livers are free from significant scarring now face an ugly reality. Since they won’t be sick enough to qualify for the drugs under the new insurance standards of treatment access, they are doomed to get sicker. Still, many public and private insurers are restricting access to treatment to those who already have serious liver damage. Since the treatment cost per patient is over $90,000 for either of the Gilead drug regimens, the insurance companies claim they simply are unable to shoulder the financial burden.

As the maker of the ultra-expensive HCV drugs Sovaldi and Harvoni, Gilead Sciences continues to refuse to comment. In a recent company brief about pricing policy, the company stated that "[t]he price of Gilead's hepatitis C treatments reflects the significant clinical, economic and public health value of these drugs."

"Everybody is trying to figure out how best to deliver needed treatments without blowing out resources because of the cost,” said Brendan Buck, a spokesman for America's Health Insurance Plans. AHIP has been an outspoken critic of the high prices for the new hepatitis c treatment drugs. In an attempt to vet the potential patients, many state Medicaid programs are requiring that patients be free of drugs and alcohol for an extended period before they will be eligible for treatment consideration.

Insurers base their coverage decisions in part on practice guidelines issued by clinical groups such as the American Association for the Study of Liver Disease. Betraying infected Americans, the organization now recommends that only patients with advanced liver disease should be given priority treatment. "Limitations of workforce and societal resources may limit the feasibility of treating all patients within a short period of time."

The claim of such limitations remains hard on HCV infected Americans seeking the new treatments to gain freedom from the virus. Caught between a rock and a hard place, they are left only with the prospect that maybe the costs will drop and the drugs made more accessible. The other possibility is the release of competing drugs that lead to a big drop in price.

As one can imagine, such hopes are weak antidotes to the despair of knowing one has a deadly disease that is progressing. It is truly horrible for so many Americans to have the awareness that their HCV infection could be treated, but their insurance companies are denying them access to a cure.

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Growing up in Manhattan as a stutterer, John Lavitt discovered that writing was the best way to express himself when the words would not come. After graduating with honors from Brown University, he lived on the Greek island of Patmos, studying with his mentor, the late American poet Robert Lax. As a writer, John’s published work includes three articles in Chicken Soup For The Soul volumes and poems in multiple poetry journals and compilations. Active in recovery, John has been the Treatment Professional News Editor for The Fix. Since 2015, he has published over 500 articles on the addiction and recovery news website. Today, he lives in Los Angeles, trying his best to be happy and creative. Find John on Facebook, Twitter, and LinkedIn.