Health Insurance Barriers To Direct Acting Antivirals (DAAs) In A U.S. Integrated Hepatitis C Virus Infection (Hcv)/Methadone Maintenance Program (MMP)

Author: Hordes MV , MacGregor DL , Sprecht-Walsh S , Barua S, Shapiro A , Hurley L , Goris E, Taylor LE

Theme: Epidemiology & Public Health Research Year: 2017

Rhode Island (RI) Medicaid, a jointly-funded federal/state partnership providing health insurance for low-income persons, supplies DAAs for patients with F3 or F4 fibrosis (METAVIR) and either non-drug/alcohol use for 6 months, or addiction treatment.

We conducted a retrospective chart review to evaluate HCV treatment during the first 21-month period of U.S. DAA availability at our integrated RI HCV/MMP.

Of 131 patients, mean age was 45 (range 22-74 years). Genotypes were 1a (62%), 1b (5%), 2 (10%), 3 (18%), 4 (4%), 6(1%). At presentation, 32 (24%) had cirrhosis. Of all patients, 96% had public health insurance (81% RI Medicaid, 15% Medicare, 1% MassachusettsHealth), 4% private.

The physician applied to insurers for DAAs for 56 patients (43%) based on restrictions, or patient request despite guidance that payers would deny; 37/56 (66%) were approved — Medicare 93% (13/14), Medicaid 58% (22/38), MassachusettsHealth 100% (1/1), private 33% (1/3). Of the 38 Medicaid recipients, 14 (37%) were denied for F0-F2, and 2 (5%) because a prescribed DAA was not on Medicaid formulary (gt3, daclatasvir; 1 cirrhotic decompensated while waiting 223 days for daclatasvir). The Medicare recipient (gt3) was denied because daclatasvir was not on formulary. Two privately insured patients were denied; 1 for F0-F2 and 1 (gt3) because sofosbuvir/velpatasvir was not on formulary.

Of 36 treated, 81% had advanced fibrosis (F3, F4); all 22 Medicaid recipients had F3 or F4. For 25 with SVR data, SVR was 80% (20/25: 1 discontinued for adverse effects; 1 virologic relapse when 16 weeks sofosbuvir/ribavirin prescribed for gt2 interferon-experienced cirrhosis but Medicaid provided 12 weeks (subsequent SVR with 24 weeks daclatasvir/sofosbuvir/ribavirin); 1 MMP discharge; 2 lost to follow-up).

DAAs are denied and inaccessible in RI due to payer restrictions. Medicaid restrictions influence private payers. Delays in adding DAAs to payer formularies and late treatment negatively impact patients.

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