More than 3 million Americans have hepatitis C (Hep C), a viral infection that affects the liver. If not treated with proper medication in time, it can lead to liver damage and even liver cancer. Harvoni and Sovaldi are two of the most effective medications to treat chronic Hep C and were approved recently (2014) by the FDA. These two treatments are known as some of the most effective ones in the market and have lesser side effects as compared to other treatments. Unfortunately, this approval has not helped patients at all. The biggest challenge facing Hep C affecting Americans today is the restricted accessibility to the medications mentioned.
A Yale University study revealed that one in four American patients’ first coverage request for Harvoni treatment is denied. Also, having Medicare/Medicaid and/or advanced liver disease increases the chances of approval. This trend is visible in most reported instances where insurance companies have denied patients’ claims for Harvoni/Sovaldi coverage on several grounds. Treatment with the latter are approved mostly for those with severe liver damage. Patients are denied treatment coverage if they are believed to be “not sick enough”; you need to have stage 3 or 4 liver cirrhosis to qualify. Another common policy is the requirement that the patient should have evidence of abstinence from drugs and alcohol (for 3 to 12 months); you may be required to take urine tests for that. Furthermore, the ratio of Hep C patients to doctors, who are authorized to prescribe Harvoni, is very high. This makes it hard for patients to find specialists who can help them through the coverage barriers that Medicare/insurance companies have created.
On what grounds can you be denied coverage?
Some requirements for denying coverage for the medication are being debated in the country. For instance, requiring drug tests is thought to have no scientific or medical basis. Coverage restrictions are largely being viewed as a cost saving measure on the part of Medicare and insurance providers. One of the most expensive drugs on the market, one Harvoni pill costs $1125 on average and can cost upto $94500 per treatment. Due to budget restrictions, state programs like Medicaid claim that they need to assign degrees of urgency to the care that eligible Hep C patients receive, and therefore prefer to treat terminal cases first.
Getting coverage for Hep C treatment is challenging and can end up wasting your time, energy and money at a time when you need them the most. Denial of coverage is quite common, however there are legal ways to seek your medical rights as an individual and as a covered policyholder. If your policy provider denied coverage of Harvoni or Solvadi to you, reach out to an experienced insurance attorney at Atkins and Markoff in Oklahoma. The insurance attorneys at Atkins and Markoff can review your current insurance plan and provide you with competitive legal representation, with all your health needs in mind.