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Will Your Insurance Cover Hepatitis C Treatment?

Understanding hepatitis C

Highlights

  1. Unlike previous treatments, newer drugs can cure HCV completely.
  2. Because these medications are expensive, you must meet several requirements for your insurance to cover your treatment.
  3. If your insurance denies your request for coverage, financial assistance programs may be able to help.

Hepatitis C is a contagious liver disease. The hepatitis C virus (HCV) causes it. HCV can spread when an uninfected person comes into contact with an infected person’s blood. The initial infection typically doesn’t produce any symptoms. Many people don’t know they have hepatitis C until liver damage shows up during a routine medical exam.

Some people may only have HCV for less than six months. This is because their body can clear up the infection on its own. This is known as acute HCV.

Most people go on to develop chronic, or long-term, HCV. According to one study, 2.5 to 4.7 million Americans are living with HCV.

Until recent years, treatment has focused on maintaining quality of life. Medications that can successfully rid the body of the virus are now available. Learn more about treatments and what insurance may cover.

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Treatments

What treatment options are available for hepatitis C?

Several medications can effectively treat HCV:

Traditional medications

Until recently, pegylated interferon and ribavirin served as the primary treatment for HCV.

Pegylated interferon is a combination of three types of proteins that stimulate the immune system. This is meant to prevent the virus from spreading. It can also protect healthy cells from infection. Ribavirin also works to keep the virus from replicating. These medications are commonly used together for “peg/riba therapy.”

Newer medications

Today, doctors use newer antiviral medications. Sometimes, people take these medications in addition to interferon and ribavirin. This is called “triple therapy.”

The U.S. Drug and Food Administration has approved the following new treatments:

Unlike previous treatments, these drugs can cure HCV. For example, Harvoni is up to 100 percent effective at clearing the virus.

These medications can carry a hefty price tag. For example, a typical 12-week course of Sovaldi can cost up to $84,000.

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Coverage

What does insurance cover?

Due to the expensive nature of these medications, you must meet several requirements to get coverage.

For example, many people have a small window of time to get coverage for Sovaldi. If your liver disease is too advanced, your insurance company can deny your request for coverage. If you begin to have severe kidney damage, then you’re no longer considered to be a good candidate for this medication.

When it comes to affording these medications, the level of coverage you may have can vary depending on your insurance plan. Many people have managed care plans.  

Contracts with healthcare providers and medical facilities are the basis for managed care plans. These plans can provide care for members at reduced costs. There are three main types of managed care plans:

  • health management
  • preferred provider
  • point of service

Most health insurance plans require treatment for HCV to be medically necessary. Whether or not treatment is medically necessary depends on each plan’s coverage policy. For example, BlueCross BlueShield of Mississippi requires that you undergo a six-month evaluation period before you can get a recommendation for antiviral therapy.

Not all health insurance plans cover all prescribed medications for HCV treatment with few exceptions. Most insurers cover Sovaldi. It has an estimated copay of $75 to $175 per month.

Check with your insurance provider to see what your individual coverage may entail. If your insurance provider doesn’t cover the antiviral therapy your doctor recommends, you may have other options for financial assistance.

Check out: Managing hepatitis C: Ways to live better »

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Supplemental coverage

Are assistance programs available?

Pharmaceutical companies, patient advocacy groups, and healthcare non-profit foundations offer supplemental coverage.

Gilead offers one such program called Support Path. The program can help you afford Sovaldi or Harvoni if you’re eligible. Most people will pay no more than $5 per copay through this program. If you’re eligible, uninsured, and seeking treatment, you can receive Sovaldi or Harvoni at no cost.

A call center is also available to help you with any insurance-related questions you may have.

If you’d like to explore your options, the American Liver Foundation provides a list of financial assistance programs.

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What you can do

What you can do now

If your doctor recommends one of these medications, your first step should be to read over your health insurance plan’s offerings. It’s important to know what your insurance will cover and what your doctor needs to provide for you to get coverage.

If you’re denied coverage initially, you can appeal the decision. Talk with your doctor about why your insurance denied your request for coverage, and work with your insurance provider to obtain treatment. If you your insurance continues to deny you coverage, look into financial assistance programs.

Keep reading: Patient perspectives: Treating hepatitis C »

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