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New York Insurers to Change Coverage of Hepatitis C Drugs
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From Jules: April 27 is this month NYS DURB hearing in Albany, will NYS Medicaid remove restrictions?
Deal requires seven insurers to cover the drugs for most patients with commercial insurance plans
By
Corinne Ramey
April 25, 2016 10:00 p.m. ET
http://www.wsj.com/articles/new-york-insurers-to-change-coverage-of-hepatitis-c-drugs-1461636001
Seven health-insurance companies in New York will change their criteria for covering costly drugs that cure chronic hepatitis C under the terms of agreements with the office of State Attorney General Eric Schneiderman.
The agreements, expected to be announced Tuesday, require the insurers to cover hepatitis C medications for nearly all patients who have commercial insurance plans in the state.
Last year, Mr. Schneiderman's office began an investigation into coverage of drugs for chronic hepatitis C, issuing subpoenas for documents and claims data to all commercial health insurers in the state. The investigation showed a wide discrepancy in how companies cover these drugs and found some insurers largely covered only patients with advanced stages of the disease, the attorney general's office said.
Five of the insurers denied from 30% to 70% of claims, the office said.
Common hepatitis C drugs include Harvoni, manufactured by pharmaceutical company Gilead Sciences Inc., which has a list price of $94,500 for a typical course of treatment.
The insurers that reached deals with the attorney general's office are Affinity Health Plan, Anthem Inc. subsidiary Empire BlueCross BlueShield, Excellus BlueCross BlueShield, HealthNow New York Inc., Independent Health Association Inc., UnitedHealth Group Inc. subsidiary Oxford Health Plans, and MVP Health Care, the attorney general's office said.
Under the terms of the agreements, the attorney general's office said it would end its investigation into these plans.
New York Health Plan Association, which represents state health insurers, said coverage guidelines continue to evolve.
"HPA believes New York should focus on affordability by taking a more aggressive position on the excessive pricing of these Hepatitis C drugs," President and Chief Executive Paul Macielak said in a statement.
MVP Health Care said the agreement is consistent with principles and practices it already has in place. The other six insurers declined to comment or didn't respond to requests for comment.
Mr. Schneiderman's office said EmblemHealth Inc. and Aetna Inc. were among the insurers it found consistently provided coverage to patients at earlier stages of the disease.
Doctors and patient advocates nationwide have accused health insurers of regularly denying coverage until patients' livers are damaged. Health insurers say the medications are prohibitively expensive, and covering such drugs can inhibit their ability to keep other costs low.
A Gilead spokeswoman said it gives insurers steep discounts. The drug is cost-effective because it saves long-term treatment costs, the spokeswoman said.
As part of their agreements, these seven insurers must cover medication for patients who don't have advanced disease and can't deny treatment for patients based on alcohol or drug use.
From 3.5 million to seven million people nationwide are estimated to have chronic hepatitis C, said Brian Edlin, a professor at Weill Cornell Medical College.
Hepatitis C is typically spread through blood contact, such as from needle use when injecting drugs.
Dr. Edlin said the agreements were a big step in the right direction, but noted they focused on commercial insurers.
"Medicaid insurers are continuing to impose these severe restrictions and onerous prior authorization processes," he said. "Consequently, this disease will become increasingly a disease of the poor, and health inequities that already exist will sharpen."
The state's Department of Health said Medicaid insurers are updating their plans in consultation with the department's recommendations to reduce restrictions consistent with changes being made by commercial plans.
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