Oregon, Illinois Medicaid Programs Place Tight Restrictions On Gilead $1,000-Per-Pill Hepatitis C Drug Sovaldi
WILSONVILLE, Ore. (AP) -- An Oregon Medicaid committee is expected Thursday to significantly scale back access to an effective—but expensive—new drug used to treat hepatitis C, the second state to retrict access to the drug in two days.
The decision would allow only a narrow set of Medicaid patients to be treated with the $1,000-per-pill drug known as Sovaldi, made by Gilead Sciences Inc.
Medical experts on Oregon's pharmaceutical review committee question whether the drug is worth the price tag, and officials worry it would break the bank. They say treating all Medicaid patients with the liver-wasting disease would cost almost as much as last year's entire drug bill.
Oregon's guidelines would allow the drug to be used only for patients with later stages of liver damage who have been compliant with previous medical treatments and drug-free for at least six months. The drug could only be prescribed by a liver specialist.
Oregon is grappling with the issue a day after Illinois' Medicaid program put in place tight restrictions on the use of the drug, including requiring patients to meet 25 criteria and get prior approval before the government program will pay for the new drug.
In Oregon, Tom Burns, director of pharmacy programs at the state's Health Authority, said it's impossible to know how many patients will make it through all the hurdles officials are seeking to place in their way.
Medicaid officials are used to covering expensive treatments, but they're usually for relatively rare conditions, said Matt Salo, director of the National Association of Medicaid Directors.
"It's always been 50 people or 500 people or 1,000 people, not hundreds of thousands like we're seeing (with Sovaldi)," Salo said. "So this is kind of a game-changer."
Oregon had about 5,600 Medicaid patients with hepatitis C at the end of 2013, before 300,000 people joined the system under the federal health overhaul. State officials say it would cost $360 million to treat all of them with Sovaldi, and total Medicaid drug spending was $377 million in 2013.
Hepatitis C surpassed AIDS as a cause of death in the U.S. in 2007, claiming an estimated 15,000 lives that year. The illness is complex, with distinct virus types requiring different treatments. While it advances gradually, it can ultimately destroy the liver, and transplants cost an average of $577,000 each.
The cost of a 12-week regimen of Sovaldi along with two companion medications that patients must also take is around $100,000. Competing regimens with other drugs cost in the mid- to high five figures, and some are far less effective and harder to tolerate.
Hepatitis C is a public health concern because the disease can be transmitted by contact with infected blood, by drug users sharing needles, and sometimes through sexual activity. Many people are unaware that they carry the virus. Health officials advise all baby boomers to get tested.
