To help defray the high costs of certain treatments and prescription drugs, like hepatitis C drug Sovaldi, insurers are figuring out different ways to cover the drugs and services by limiting who can have access to them, reported Kaiser Health News.
Many insurers, for example, will only pay for Sovaldi if their members have serious liver damage. Others are restricting who can prescribe the drug or are requiring evidence that the drug is working before they approve further treatment.
"Everybody is trying to figure out how best to deliver needed treatments without blowing out resources because of the cost," Brendan Buck, a spokesman for America's Health Insurance Plans, told KHN. AHIP has slammed the drug industry for the soaring costs of specialty meds like Sovaldi because they're taking unfair advantage of insurers, FierceHealthPayer previously reported.
Blue Cross Blue Shield of Texas, for example, denied one physician's request to cover Sovaldi for a member because the insurer rarely pays for the medication if the member is in the early stages of the liver disease.
But some industry experts worry that coverage denials like BCBST's could actually be causing a public health problem. "We can address hepatitis C and eradicate it," Ryan Clary, executive director of the National Viral Hepatitis Roundtable, told KHN.
What's more, a CVS Health Research analysis released last month showed that 8 percent of almost 2,000 patients managed by CVS/caremark, the CVS Health pharmacy benefit management business, who filled prescriptions for the drug, discontinued Sovaldi.