Abstract #1759 Differential Access to Direct Acting Antivirals (DAAs) Across Federal, State, Commercial, and Manufacturer Patient Assistance Programs (MPAP) – Jane Giang, et al.
Insurance denials for hepatitis C treatment are preventing access to care for some people. The purpose of this retrospective study was to see if there were more barriers to treatment among specific types of payers. The study enrolled medical center patients who were prescribed HCV treatment using DAAs between October 2014 and April 2016. Treatment was prescribed regardless of known payer restrictions and the study used a designated pharmacist familiar with payer criteria. Note that this center was in a state that opted out of Medicaid expansion under the Affordable Care Act.
Beginning with initial prior authorizations, 794 cases were approved and 206 were denied. Medicaid had the highest rate of denials (nearly 39%) compared to commercial payers (25%), Medicare (12%) or MPAP (2%). Of those initially denied, 146 were appealed of which 115 were eventually approved. Medicare had the highest approval rate; Medicaid had the lowest, and both had the most successful appeals at around 93%. Appeals had a nearly 72% success rate for commercial plans.
The most common reasons for denial were mild liver damage (<F2 fibrosis), not meeting criteria, non-formulary/plan exclusions and missing info. However, all but the mild fibrosis level denials had successful appeals above 90%. Patients with <F2 fibrosis were only able to gain access to DAAs about 47.6% of the time.
Conclusion: Around 90% of cases eventually had access to DAAs. Those with the most success were patients insured by Medicare and non-insured patients who used the Manufacturer Patient Assistance Programs. Medicaid is still problematic in that the denial rates are high and appeals are not all being submitted. There is still a problem with treatment access for patients with mild fibrosis.
Editorial Comments: There are no excuses for these denials. Plain and simple, approvals should be 100%. The next abstract is one of many studies showing why we need to offer HCV treatment to people at all stages of fibrosis.
Lucinda K. Porter, RN, is a long-time contributor to the HCV Advocate and author of “Free from Hepatitis C” and “Hepatitis C One Step at a Time.” She blogs at www.LucindaPorterRN.com and HepMag.com
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