One in Three People Seeking Insurance Coverage for Hep C Drugs Are Denied

[Hep Editors]

A considerable, and rising, proportion of people who apply to their insurance companies for coverage of hepatitis C virus (HCV) medications are flat-out denied.

Publishing their findings in Open Forum Infectious Diseases, researchers conducted a prospective cohort study among 9,025 people from 45 U.S. states who were prescribed a direct-acting antiviral (DAA) regimen for HCV and had a prescription submitted between January 2015 and April 2015 to Diplomat Pharmacy Inc. This company provides hep C pharmacy services across the nation.

Read more...
https://www.hepmag.com/article/one-three-people-seeking-insurance-coverage-hep-c-drugs-denied

[dragonslayer]

There seems to be an important discrepancy in the reports regarding the date range of prescriptions submitted and denied.

In the HEPCMAG article, https://www.hepmag.com/article/one-three-people-seeking-insurance-coverage-hep-c-drugs-denied , it says: 

"Publishing their findings in Open Forum Infectious Diseases, researchers conducted a prospective cohort study among 9,025 people from 45 U.S. states who were prescribed a direct-acting antiviral (DAA) regimen for HCV and had a prescription submitted between January 2015 and April 2015 to Diplomat Pharmacy Inc. This company provides hep C pharmacy services across the nation."

However, in the quoted EurekaAlert press release, https://www.eurekalert.org/pub_releases/2018-06/idso-idf060518.php , it says:

"researchers used data from Diplomat Pharmacy Inc., which provides specialty pharmaceuticals, including direct-acting antiviral drugs for the treatment of hepatitis C, to patients in 45 U.S. states. Their analysis included 9,025 patients who had prescriptions for these drugs submitted to the pharmacy between January 2016 and April 2017."

Clearly, from what weve seen, denials were much higher when these drugs were first  approved for use, and if  January - April 2015 is the correct date of the prescription submissions, we would expect early denials to have been more prevalent than later as it would have represented the initial batch of Harvoni submissions. As we know it took a while for the insurance companies to come around.

But if the 2017 date range is correct, that obviously is much more concerning.

[badbradley]

Browsing through my research I found this

Absolute Insurer Denial of Direct-Acting Antiviral Therapy for Hepatitis C: A National Specialty Pharmacy Cohort Study

https://jumpshare.com/v/9XI7En9muDeRr5bk0KoS

For DAA prescriptions submitted to a national specialty pharmacy between January 2016 and April 2017, 35.5% were absolutely denied by the insurance carrier.
.....denial  was  higher  among  commercially  insured  (52.4%)  and  Medicaid (34.5%) beneficiaries compared with Medicare beneficiaries (14.7%). Notably, the incidence of denial increased for all insurance types over subsequent quarters during the observation  period.  Finally,  the  incidence  of  absolute  DAA  denial  varied by type of insurance within and across states.
 Contrary  to  our  hypothesis,  the  overall  incidence  of  absolute  denial  in  this  study  (35.5%)  was  substantially  higher  in  magnitude  than  that  observed  in  2  prior  analyses  conducted  shortly  after  the  release  of  all-oral  DAA  regimens  (absolute  denial  range,  8.2%–16.2%)  [17, 18].
     In  prior  studies, denial  of  DAA  therapy  was  reported  to  occur  in  as  high  as  46.3%  of  Medicaid  beneficiaries  [17, 18]. In  contrast,  the  results  of  the  present  study  indicate  that  the  overall  incidence  of  absolute  denial  of  DAAs  is  now  lower  in  magnitude  for  Medicaid  beneficiaries  (34.5%).
      Throughout  the  observation  period,  the  incidence  of  absolute  denial  was  more  common  among  patients  covered  by  commercial  insurance  (52.4%)  than  by  Medicaid  (34.5%,  P  <  .001)  or  Medicare  (14.7%,  P  <  .001).