Hepatitis C Drugs: Insurers' Reasons for Coverage Denials

Treating hepatitis C with new antivirals saves lives and—in the long run—money spent on patient care.

But some patients and their physicians are learning there are barriers to getting prescriptions approved by patients’ carriers.

In a study presented at the 2015 Digestive Disease Week conference in Washington, DC, a Geisinger Medical Center research team looked at reasons insurers gave for refusing to pay for these medications.

Amir Rezk, MD, and colleagues at the Danville, PA hospital’s gastroenterology & hepatology and internal medicine departments looked at the medical records of 50 patients at their hospital denied coverage for a hepatitis C antiviral out of in a group of 163 with hepatitis C infections. All had been given prescriptions for sofosbuvir (Sovaldi/Gilead).

The reasons for denial were that these patients either had a low fibrosis score (12 patients), continuing alcohol or substance abuse problems (10 patients), inadequate lab reports (10 patients), lack of documentation of medical necessity (5 patients) or that the medication was not on the insurer’s formulary (4 patients). Other reasons for denial were that the prescription was part of a regimen not approved by the US Food and Drug Administration (3 patients), the patient’s Child-Pugh-Turcotte score was too high (2 patients) and other miscellaneous causes (4 patients).

On appeal, physicians were able to get the denials overturned in 10 cases, 5 of them denials due to documentation being missing.

These denials can be frustrating, the team wrote. “The advent of these antivirals has expanded the pool of treatment candidates, but financial and logistical barriers preclude widespread treatment,” they wrote.

“The medication cost is high, leading the insurance companies to formulate criteria to restrict therapy,” they continued.

Their analysis at Geisinger showed most common reasons were low fibrosis score and continuing substance abuse.

“Medical providers prescribing sofosbuvir can minimize potential barriers to treatment by understanding these current issues related to treatment,” they concluded.