November 6, 2015 — Federal officials are warning that state Medicaid programs may be violating the law by restricting access to the hepatitis C drugs Sovaldi and Harvoni.
The Wall Street Journal reports that the Centers for Medicare and Medicaid Services (CMS) wrote that some states may be “imposing conditions for coverage that may unreasonably restrict access.”
Federal law requires Medicaid programs to pay for all “medically necessary” treatments, defined as any use approved by the FDA.
Medicaid programs commonly restrict coverage for Sovaldi and Harvoni to patients with severe liver scarring (cirrhosis). Many states also require abstinence from drugs and alcohol. Patient advocates say the FDA-approved labels do not include such restrictions.
Hepatitis C was considered incurable until 2013, when Sovaldi and Harvoni were approved. But with a $95,000 price-tag for a 12-week treatment, most patients have had to rely on private insurance or Medicaid. Unfortunately, many of them are being told they aren’t sick enough to obtain coverage.
In the last year, 94% of hepatitis C patients in California who requested the drugs through Medi-Cal were denied coverage, according to the Los Angeles Daily News.
Texas — the state with the third-largest Medicaid population after California and New York — was the only state that spent nothing on Sovaldi last year. A spokeswoman said “price was the biggest issue,” the Wall Street Journal reports.