If you’re prescribed a breakthrough drug for hepatitis C, here are four steps to protect your pocketbook…

When the newer-generation of direct-acting antiviral drugs for hepatitis C first emerged, they were extremely expensive, and some insurers wouldn’t pay for them—or would pay only for patients with advanced scarring of the liver.

Earlier drugs cost up to $90,000 for a full course of treatment. But the price for the latest breakthrough drug, glecaprevir/pibrentsavir (Mavyret), which is effective for all hepatitis C genotypes in people without cirrhosis, is much less expensive—about $26,000 for the standard eight-week regimen.

A troubling finding: More than one-third of 9,000 Americans prescribed a direct-acting antiviral regimen were denied coverage by their insurer, including 52% with private insurance, according to a study published in 2018 in Open Forum Infectious Diseases

However: As prices have declined, most Americans are now gaining access to these highly effective antivirals.

Even though most health insurers will cover the drugs, sometimes the insurer—rather than your doctor—might decide which medication you get. 

If you’re denied coverage, consider trying these steps…

  • Preempt the problem. Ask your doctor to fill out a preauthorization form to get approval from the insurer before prescribing a new hepatitis C drug. This may preempt a possible denial from your insurer.
  • Appeal! Be the squeaky wheel and appeal an insurer’s decision to deny coverage. Don’t assume the insurer won’t pay—this is simply its first response. Appeals generally have a high success rate.
  • Look into PAPs. Through patient-assistance programs (PAPs), many drug manufacturers provide free medication for those who have financial need and/or no health insurance or those for whom insurance coverage was denied. Sponsored by pharmaceutical companies and other organizations, these programs often require proof of limited income. The doctor’s office staff often can help with the paperwork that’s required to participate in a PAP.
  • Co-pay assistance programs. Many manufacturers offer co-pay assistance cards for patients who have expensive co-payments. Ask your doctor if you qualify.

Source: Eric Lawitz, MD, a professor of medicine at University of Texas Health San Antonio and vice president of scientific and research development for the Texas Liver Institute, also in San Antonio. He has more than 300 publications in leading scientific journals. He also serves as a reviewer for many journals, including The New England Journal of Medicine, The Lancet, Gastroenterology, American Journal of Gastroenterology and Journal of Hepatology. www.TXLiver.com