Lawsuits challenge Medicaid policies on covering hepatitis C drugs

Some states have denied Medicaid coverage for effective yet expensive hepatitis C drugs to patients and prisoners, and class-action lawsuits challenging those decisions could end up costing the states hundreds of millions of dollars, according to an article from The Pew Charitable Trusts.

The treatments cost between $83,000 and $95,000 for a single dose and boast a 95 percent cure rate, the article states. 

Hepatitis C patients often have to delay treatment if they don't have insurance, and while Medicaid does cover some expensive hepatitis C drugs, it only covers them for people who are in the late stages of the disease. Meanwhile, patients on Medicaid who are waiting to reach that state may develop cirrhosis or liver cancer, or they may even have liver failure, which could require a transplant, the article says. Medicaid patients have been denied coverage for expensive hepatitis C medications in the past due to Medicaid determining that their treatment was not a "medical necessity," FierceHealthPayer has reported.

In the last eight months, numerous class-action lawsuits have been filed in four states--Indiana, Massachusetts, Minnesota and Pennsylvania--claiming that by denying drugs to hepatitis C patients, states are violating the Affordable Care Act provision that says Medicaid can only deny coverage for drugs that are not "for a medically accepted indication" by the Food and Drug Administration. But some are concerned with the economic effects of covering such a high-cost treatments.

"We would be spending more on this one drug than all other drugs combined," Matt Salo, executive director of the National Association of State Medicaid Directors, said in the report. "There isn't the capacity to do that."

Federal court cases have determined that the standard of medical care in prisons can be lower, allowing them to deliver treatment in any way they see fit, as long as that delivery doesn't cause a serious indifference to a medical need, the article adds.

Private payers also are grappling with the high cost of hepatitis C treatments, and in reponse have negotiated with pharmaceutical companies to secure discounts.

To learn more:
- here is the article

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